# Medication Math for the Nursing Student A Brief Introduction to Dimensional Analysis: So what's the big idea, anyway

? Take the test: 25 practice problems--have fun with your brain. Review the test with complete answers: Get your intro to dimensional analysis here. Conversion factors for Nursing Students: Copy and make your own cheat-sheet Abbreviations for Nursing Students: Know'm and love'm MedMath Errors and the Nursing Student: Be afraid, be very afraid My Adventures in Med-Math: Or how I came to post so much stuff on this Web site A Guide to Dimensional Analysis: The one-page all-you-really-need-to-know guide How to Minimize Mistakes: You could save a life Dimensional Analysis Summary: A few tips A Critique of Clinical Calculations: A unified approach, 4th ed. Recommended Corrections to Clinical Calculations: A unified approach Dimensional Analysis for everyone else: Some general examples here More examples of Dimensional Analysis: Drug calculations MedMath and your PDA: Files and programs you can use

Go to top

Medication Math Errors and the Nursing Student

A shocking number of patients die every year in United States hospitals as the result of medication errors, and many more are harmed. One widely cited estimate (Institute of Medicine, 2000) places the toll at 44,000 to 98,000 deaths, making death by medication "misadventure" greater than all highway accidents, breast cancer, or AIDS. If this estimate is in the ballpark, then nurses (and patients) beware: Medication errors are the forth to sixth leading cause of death in America. How many medication errors are miscalculation errors? No one really knows since by some estimates as little as one in ten errors are reported (Pepper, 2002). Of reported errors one FDA study (Thomas, et. al., 2001) found that 7% were due to "miscalculation of dosage or infusion rate." Combining this estimate with the estimate for total deaths, as many as 3,000 to 6,800 deaths are caused annually by medication math errors. This would mean that in the average hospital one patient dies every year or two because someone makes a miscalculation, and one or two patients are sub-lethally harmed each month. As future nurses, then, there is a distinct possibility that we will harm, or even cause the death of, a patient over the course of our career. If we believe the adage "first do no harm" applies to us, then what can we possibly do to minimize miscalculation errors? If we only aim to pass Medication Math with an 80% or above, are we setting the bar high enough? It might be late some Saturday night, you're the only RN on the floor, the hospital pharmacy is closed, and it's up to you to calculate a needed dosage. Surely getting the right answer only 80% of the time is not acceptable. Perhaps the problem you need to solve is a little different than any you've seen before or recall seeing in the textbook. How confident will you be that your calculation is correct? The time to build confidence is while we are students. I suggest that as conscientious students we should aim for 95% or better. We should, then, carefully study, learn from, and thereby avoid repeating what mistakes we do make, so that by the time we are working in the real world we can be confident that, if we are vigilant enough, we can approach 100% proficiency. Since "to err is human," we will always be at risk of not achieving a goal of 100% proficiency, but we cannot aim for less, and knowing that we are always at risk will make us extremely careful. Neither effort, desire to avoid error, nor carefulness, however, is enough. We need the right tools and techniques that will help us avoid miscalculations. I believe that dimensional analysis is the most appropriate tool available to us. It is, by far, the best method of solving medication math problems with the least chance of making errors. As nurses we're not likely to ever use whatever algebra, trigonometry, calculus, or statistics we may know and (even better?) we need make no effort to learn these subjects, but we should strive for a deep understanding of, and proficiency in, dimensional analysis (DA). The good news is that mastery of DA is not at all an unobtainable goal. While few could master a vast subject such as algebra in a lifetime, most students should be able to master DA in a few weeks of focused effort. Mastery would mean the ability to solve any problem that could crop up, no matter how it is presented, while avoiding pitfalls, and retaining proficiency in the years to come. Needless to say, if I thought that nursing students were mastering DA, I wouldn't be writing this paper. The bad news, then, is that most nursing students seem to have a weak understanding of DA. Most can follow examples given in the textbook; they can then solve all the practice problems

that follow the same general format. If quizzes or tests also follow the textbook examples, most students succeed brilliantly. That all is not well, however, is apparent went problems do not meet expectations. One sophomore class stumbled badly on a test apparently for this reason. They could all follow, if imitatively, the examples in the textbook, and could therefore do all the practice problems, but when the test presented problems in an unexpected format, most failed--only 2 students passed the test. In their final semester before graduating as RNs, a third failed another test. This suggests a weak understanding of DA. Unfortunately most students have almost, but not quite, a complete understanding of DA. I believe this is due to the textbook used (Clinical Calculations: A unified approach, 4th ed.) almost, but not quite, presenting a complete description of DA. It may be that there are too few nurse/mathematicians to write textbooks, and so a weak foundation for DA is laid for students to build on. My aim in writing this paper is to provide nursing students with a more robust foundation to build on, and perhaps reduce future misadventures. I am not a mathematician, but I have been doing DA for 30 years, have made refinements in the technique over that time, and as a substitute teacher I have taught it to middle and high school students. Dimensional analysis is your friend. Embrace it; learn to love it. It is our best defense against doing harm to a patient by miscalculation.

Go to top

**My Adventures in Med-Math
**

I did my first med-math problems when my wife was in nursing school. She's pretty sharp and no math weenie, but some problems proved frustrating and she'd say, "Okay Mr. Math Guy, see if you can solve this one." I'd do the old bing-bang-boom, and offer up the (correct) answer. Once I got the old, "Ha! You're wrong, the answer key says it's ..." to which I helpfully replied, "When you go to class tomorrow be sure to let your instructor know her answer key needs correction." Somehow I gave the impression of being some sort of math whiz, which I knew not to be the case, but damned if I was going to admit it to her--I didn't want her thinking she was smarter than me in everything! Unfortunately, at the time, I didn't pay any attention to how nursing students were being taught to do med-math, and she, asking only for the answer, paid no attention to how I so easily and annoyingly came up with the right answer every time. As it happened, during her first year she was taught the traditional (for nurses) approach using ratios, proportions, and formulas. Then during her second year, the school switched over to the new fangled (for nurses) approach based on dimensional analysis. A couple of years later our daughter started nursing school (I started the next year), and I got to hear all the med-math horror stories about how many did or didn't pass the latest med-math quiz (these were given throughout the year after everyone had passed the 8-week med-math class) and

had to attend remedial classes (on the dreaded titration quiz only two students in her class passed the first time!). Unfortunately, once again, I didn't look into how she and other nursing students were being taught to do dimensional analysis. I just thought there was something about medmath problems that made them incredibly difficult to solve. I should have known that there was something horribly wrong. I had learned to do dimensional analysis (DA) some thirty years earlier when I was taking a lot of chemistry classes. I've happily used DA ever since and had never encountered an applied math problem in chemistry, physics, or engineering that DA couldn't readily dispatch, and yet I was willing to assume that med-math problems, with the exception of the ones I had done myself, were somehow different and intrinsically harder. I'm such a bloody moron! It wasn't until I started nursing school and took the obligatory med-math class that I finally realized what was going on. I had an hour or so to kill before the first class, so I opened the textbook to glance through it. Before class began, I had realized, with growing shock and disbelief, that the authors of the textbook didn't understand the technique they were attempting to teach to nursing students. There were serious errors of omission--things you really need to know to do DA right and well. And there were serious errors of commission--using techniques and the language of math so badly as to give the text a distinct air of innumeracy. I was convinced that if I had had to learn DA from this book, I would be at serious risk of not passing the class. My next thought was, "Hmm, wonder where the instructor learned to do DA?" So here I was in an 8-week class with nothing to do apart from memorize a few abbreviations and conversion factors. The instructor made a good show of pretending she knew what the textbook was talking about. Instead of risking doing problems on the board herself, she deftly had students, a half dozen or so at a time, come up to the board to do problems from the text. Then she would point to each problem in turn and ask if everyone got the same answer. If anyone thought the answer wrong, they got to explain how they came up with the right answer. This actually worked out rather well as several students had enough sense to ignore the textbook and figure out how to do the problems in spite of the book. Since I had a lot of spare time, I decide to see if I could do something to improve the situation. Perhaps a critique of the text with suggested corrections would help. Better, I could explain how I was taught to do DA with the gentle hint that maybe the Ph.D. chemist who taught me understood DA better than the nurses who wrote the textbook. I got started, getting my thoughts together in writing, that first week of class. Part of the situation was that here's a freshman nursing student, O ye of zero credibility, seriously thinking about calling into question the mathematical acuity of textbook authors with advanced degrees (in nursing), and implying that those teaching or who have taught the class, having learned DA from the book, didn't quite know what they were doing either. I needed to be careful and make sure I knew what I was doing. My first reality check was to mention my assessment of the textbook to a fellow student known to have a good grounding in science and math. He immediately agreed that the authors were confused, but as he was doing fine, he didn't seem interested in offering any corrections--a wiser man than I. The only students to get in serious trouble were the ones who spent way too much time reading the book. I recall two who had taken the class over the summer and had failed it. They were taking it again and knew they'd be dropped from the program if they failed again. The pressure

was on, and they just weren't getting it. The instructor tried without success then asked me to tutor them. I assured them I could help, but that I wasn't going to teach them to do DA the book way. They thanked me for the offer, but decided not to risk being confused any more than they already were, and to tough it out in the hope that, with enough effort, they would at last master med-math by the book. Sadly, these were the two who were dropped because they couldn't pass med-math. There were others more willing to let me confuse them, but all reported that my clairifications were helpful. One student asked me a couple of days before the final how to pick a starting factor (something the text fails to mention), and reported the next day that she tried my technique out on various problems the night before and that it worked! She later mentioned getting 100% on the final. As the hours put in to the project began to mount up, I thought of spinning my work into an Honor's Project, which would involve some faculty involvement and oversight. I was given the nod to go ahead, but from there on I pretty much did my own thing. At the end there would be an Honor's Colloquium, and I'd invite all the faculty listen to my presentation. I realized that my presumptuousness was off the scale, and even I found it difficult to consider the possibility that I might be right. I needed to consult with someone whose mathematical acuity was beyond reasonable doubt, someone whose judgement I could completely trust. Ideally I wanted someone whose math ability was off the scale. Steven Hawking was too busy, or so he claimed, working on another project--something about a theory of everything, so I had to find someone else. I emailed Jef Raskin about my problem who replied that he was a strong supporter of DA and was willing to help. Jef Raskin may not be a household name, but Jef is the creator of the Macintosh computer and was lead designer of the Mac OS. Prior to that he was a professor of computer science at UCSD, and since then, apart from being known widely as a human interface guru, he has written over 300 articles and books on science, math, and technology issues. I really like this guy, and as a bonus his wife is a nurse with advanced degrees (which is what made me think he'd take an interest). I sent Jef copies of the textbook, those portions I found questionable, so he could form his own opinion. Basically he agreed that the authors' presentation of DA was "illogical and incorrect." But he went on to explain that gifted scientists and mathematicians use a different technique, namely none at all. Problems are approached from first principles and reasoned through to the answer that makes sense. This approach, the think-it-through technique, is slow and error is a risk, but the aim is to understand deeply and not merely crank out the right answer using some superficial technique. Of course, for those of us less gifted folk, superficial technique that gives us the right answer every time looks pretty darn good. It was a pleasure and a privilege to correspond with Jef. I didn't mention my correspondence with Jef to my project mentor or other faculty. I felt that my critique and suggestions should stand on their own merit. I was prepared to argue my points based on evidence and reason, and felt that to play the Authority Card to gain credibility would be in bad form. In hindsight I probably should have in order to gain enough credibility to be listened to in the first place.

When all the students at the college who had done Honor's Projects were scheduled to present, I was the only nursing student on the list. I personally invited the Director of Nursing and any faculty who might be interested to attend. My presentation went well and was well received by the 30 or so academics present. Unfortunately, due to schedule conflicts, no one from the nursing department was able to attend. On the off chance that someone out there in cyber land would be interested in my work, I posted some stuff on a Web site. I hope someone out there is being helped. As my first year of nursing school came to a close, I told the Director of Nursing I would be willing to meet with her and any interested faculty to explain my concerns about the med-math program at a time of their convenience. She said she'd let me know, and here I must note that I detected or imagined some annoyance on her part that I was bringing up the subject yet again. At any rate she never called and I never offered again. At the end of my final year of nursing school I felt I had an ethical responsibly to try again. I contacted by email the instructor currently teaching med-math (not the one I had had), and shamelessly played the Authority Card. This got me a meeting. She was receptive, mentioning straight off that she had already come to the conclusion that there was something not quite right with the textbook, but had yet to determine what it was. Needless to say I had plenty to say on that point. I was given time to make my case, felt I was listened to, and that all points were taken. I don't know if med-math students are doing any better as a result, but one can always hope.

Go to top

**A Brief Introduction to Dimensional Analysis
**

When you're doing applied math, numbers have units of measure, or "dimensions," attached to them. Someone noticed that when you plug values into a formula and pay close attention to what happens to the units as the formula is simplified, you'll see that most of the units cancel out and you're left with only those units that end up in your answer. This always happens if the formula is correct and you plug in the appropriate factors. So then someone figured out that you don't need formulas at all. For every problem you can just take the factors associated with it, pick a logical factor to start with, then add others until all the units you don't want cancel out and you're left with only the one or ones you do want (which is why you determine the answer units first). This process is fairly trivial, and with only slight attention to detail, you always get the right answer. The technique has been taught to students of applied science for longer than I have been able to determine and for the sole reason that students using it make fewer mistakes. You pay attention to the units of measure and if they're not canceling out right, you have a major clue you're doing something wrong and that your answer is guaranteed to be wrong.

As nurses doing calculations, error is not an option. Passing med-math may require getting 80% of test problems right, but coming up with the right answer only four out of five times isn't good enough. While mistakes can still be made using any technique, dimensional analysis does the best job of minimizing them. The only fault lies in the name. Perhaps The Math-Weenie NoBrainer Technique would be more appropriate. Go to top

**A Step by Step Guide to Dimensional Analysis
**

The following summary can be used as a guide for doing DA. Some familiarity with DA is assumed. See the answers to the self test for a detailed explaination of DA. While not all steps listed below will be needed to solve all problems, I have found that any problem that can be solved using DA will yield its answer if the following steps are followed. I would not suggest memorizing the sequence of steps, but rather understanding and practicing them. Understanding is more durable than memory. 1. Determine what you want to know. Read the problem and identify what you're being asked to figure out, e.g. "how many milligrams are in a liter of solution." a. Rephrase if necessary using "per." Example: You want to know "milligrams per liter." b. Translate into "math terms" using appropriate abbreviations to end up with "mg/L" as your answer unit (AU). Write this down, e.g. "AU= mg/L" 2. Determine what you already know. a. What are you given by the problem, if anything? Example: "In one minute, you counted 45 drops." Rephrase if necessary. Think: "Drip rate is 45 drops per minute." Translate into math terms using abbreviations, e.g. "45 gtt/min" If a given is in the form mg/kg/day, rewrite as mg/kg x day (see example 4) If a percentage is given, e.g. 25%, rewrite as 25/100 with appropriate labels (see example 5) b. Determine conversion factors that may be needed and write them in a form you can use, such as "60 min/1 hour." You will need enough to form a "bridge" to your answer unit(s). See example 1. Factors known from memory: You may know that 1 kg = 2.2 lb, so write down "1 kg/2.2 lb" and/or "2.2 lb/1 kg" as conversion factors you may need. Factors from a conversion table: If the table says "to convert from lb to kg multiply by 2.2," then write down "2.2 lb/1 kg" 3. Setup the problem using only what you need to know. a. Pick a starting factor. If possible, pick from what you know a factor having one of the units that's also in your answer unit and that's in the right place. See example 1.

Or pick a factor that is given, such as what the physician ordered. Note that the starting factor will always have at least one unit not in the desired answer unit(s) that will need to be changed by canceling it out. b. Pick from what you know a conversion factor that cancels out a unit in the starting factor that you don't want. See example 1. c. Keep picking from what you know factors that cancel out units you don't want until you end up with only the units (answer units) you do want. d. If you can't get to what you want, try picking a different starting factor, or checking for a needed conversion factor. e. If an intermediate result must be rounded to a whole number, such as drops/dose which can only be administered in whole drops, setup as a separate sub-problem, solve, then use the rounded off answer as a new starting factor. See example 9. 4. Solve: Make sure all the units other than the answer units cancel out, then do the math. a. Simplify the numbers by cancellation. If the same number is on the top and bottom, cancel them out. b. Multiply all the top numbers together, then divide into that number all the bottom numbers. c. Double check to make sure you didn't press a wrong calculator key by dividing the first top number by the first bottom number, alternating until finished, then comparing the answer to the first one. Miskeying is a significant source of error, so always double check. d. Round off the calculated answer. Be realistic. If you round off 74.733333 to 74.73 mL that implies that all measurements were of an extreme accuracy and that the answer is known to fall between 74.725 and 74.735, or 74.73 + 0.005 mL. A more realistic answer would probably be 74.7 mL or 75 mL. See example 6. If you round to a whole number that implies a greater accuracy than is appropriate, write your answer to indicate a range, such as 75 + 5 mL. See example 9. e. Add labels (the answer unit) to the appropriately rounded number to get your answer. Compare units in answer to answer units recorded from first step. 5. Take a few seconds and ask yourself if the answer you came up with makes sense. If it doesn't, start over.

This is a fairly bare outline, so refer to Appendix A for examples. The steps are best taught, rather than read, and so would serve better as a guide to tutoring students than as a self-teaching guide. Go to top

**How to Minimize Mistakes
**

Anything we can do to reduce errors by even the smallest degree is worth doing. How we choose to write down a DA problem, for example, can make a difference. Should we just keep the answer unit in mind, circle it in the problem, or actually write it down? At best we will hit what we aim for, so we must be very clear about what we want, about the answer unit(s) we are

aiming for. Reading the problem with the sole, focused purpose of determining the answer unit, then writing it down (least we forget or get confused later on) is an example of good technique. You can be sloppy and still get the right answers most of the time, but eventually you'll blunder because of poor technique. You'll triumphantly, like me, write down "4.3 mL/min" as your answer forgetting that you were supposed to calculate "mL/hr" and all because you neglected to write down the answer units and compare them with your answer. DA problems are often written in fraction form, even though they are factors and shouldn't be confused with fractions. Fractions cannot be inverted and remain correct, 2/3 is not equal to 3/2, while factors can be (3 tsp/1 tbs is equivalent to saying 1 tbs/3 tsp.

When it comes time to do the math, the first number can be overlooked, especially if you're using scratch paper with other problems on it, perhaps because it is visually different and not in line with other values. An error of omission is less likely using the following non-fraction format:

This format is more visually integrated, more bridge like, and is more appropriate for working with factors. It is also less confusing when doing amounts-per-body-weight-per-dose or day calculations. In this format, the horizontal bar means "divide," and vertical bars mean "multiply." Occasionally a factor like "50 kg" will need to be divided rather than multiplied which could cause confusion or errors when doing the math if the division sign is not noticed when written in fraction form.

Since the first factor is normally multiplied, students might stumble if division is required and divide everything into 50, an error, instead of multiplying 250x50x1000, then dividing by 50 and 500. When written in factor form using bars, mistakes and confusion are minimized:

This is, then, another reason to avoid the fraction format. Perhaps with the exception of conversion factors you have memorized, it is advisable to actually write down, in "math terms" or factor form anything given to you by the problem as well as any conversion factors you had to look up. Often the hardest part of a problem is translating fuzzy English phrasing into crisp math terms you can use.

Use abbreviations that are clear and label numbers fully. Using a degree symbol for hour instead of "hr" is an invitation to error. If the degree symbol is written a little too big it could be mistaken for a zero resulting in an order of magnitude error. When doing the math, the brain is looking for numbers and could see "10" where a "1" is meant:

Avoid "cc" and use "mL" instead as cc can look like zeros. Likewise don't use U for unit. Write 5 units insulin, and not 5U insulin, which could be mistaken for 50. When writing numbers less than one, always start with a zero, so write 0.4 and not .4 as the point could be overlooked. When writing whole numbers omit writing a point zero to indicate that the measurement was made to the nearest tenth (or point zero zero to indicate an accuracy of plus or minus a hundreth) as you would in science lab. In med-math a hand written 5.0 could be mistaken for 50 if the point were over looked. Another abbreviation to avoid is using Mu ( µ ) for micro as in microgram (µ g). When handwritten, "µ " can look like an "m" and so "µ g" looks like "mg" which could lead to a three orders of magnitude error. The preferred abbreviation, then, is "mc" for "micro" as in "mcg" for "microgram." If you were doing calculations involving milliliter volumes of three solutions, A, B, and C, then do not use "mL" alone without specifying "mL of what?" Your labels, then, would be in the form "23 mL A" or "3 mL C" and you would know to only cancel out "mL B" with "mL B." Whenever you label any number with a unit of measure, always be aware that you are dealing with grams of something or liters of something, and so on. It may therefore be helpful to label fully rather than minimally. Writing "25 mL NS" is much clearer than just "25 mL." In some problems, failure to fully label numbers can lead to serious confusion and error.

Conclusions

Errors may be unavoidable in absolute terms, but we can minimize the number of errors we make. A good understanding of dimensional analysis is our best defense against miscalculation errors. With practice all nursing students can acquire a high level of proficiency in doing medication math.

R. Eric Lee, RN busybee@alysion.org

References

Institute of Medicine (2000) To Err Is Human: Building a Safer Health System National Academy Press. Available online: http://www4.nas.edu/news.nsf/isbn/0309068371? OpenDocument Pepper, Ginette A. (2002) Errors in drug administration by nurses from Understanding and Preventing Drug Misadventures Conference. Available online: http://www.ashp.org/public/proad/mederror/pep.html Thomas MR; Hoquist C; Phillips J. (Oct. 1, 2001) Med error reports to FDA show a mixed bag. Drug Topics; 145(19); 23. Available online: http://www.fda.gov/cder/drug/MedErrors/mixed.pdf Go to top

**MedMath Practice Problems for Nursing Students
**

The following problems will test your math ability without wasting your time with repetitive problems. Each problem is a mini-test of some important concept. If you miss any question, review the underlying concept. If you get them all right, ask if you can take the final. General Math Which of the following statements are True? 1. 20/48 = 5/12 2. 16/5 = 3 1/5 3. 1 7/8 = 15/8 4. 2/3 + 3/4 = 19/12 5. 5/9 + 2/3 = 1 2/9 6. 10 1/5 - 6 3/5 = 3 3/5 7. 7 1/8 x 3/4 = 5 11/32 8. 5/8 ÷ 1/16 = 10 9. 35% = 0.35 10. xiv = 14 See Answers

Dimensional Analysis Problems (see Conversion Factors for Nursing Students)

1. Just as a warm up, how many seconds are in a day?

2. You are to give "gr 5 FeSO4" but the available bottle gives only the milligrams of iron sulfate per tablet (325 mg/tab). How many milligrams is the order for? (Yes, this and several of the other problems are ones I've actually encountered in my nursing practice.)

3. You just opened a 500-mL bottle of guaifenesin and will be giving 1 tablespoon per dose. How many doses are in the bottle? In other words how many tablespoons are in 500 mL?

4. You give your home health patient an unopened 500-mL bottle of guaifenesin and tell them to take 2 teaspoons 4 times a day as ordered. They ask you how long the bottle will last.

5. Your order is for meperidine (Demerol) 35 mg, IM, STAT. Available is a 2-mL vial containing 50 mg/mL meperidine. On hand are 1 cc and 3 cc syringes. How much should you draw up into which syringe?

6. You are shadowing a nurse during a clinical who receives an order to adjust the infusion rate of a pump so that 1.6 mg of lidocaine are being delivered per minute. Hanging is a 100 cc piggyback containing 0.4 grams lidocaine, a 0.4% solution. Without writing anything down, the

nurse tries to solve the problem on a calculator. After the fifth different and incorrect answer you find a piece of scratch paper and offer to show her how to set up the problem. She assures you she can always do problems like this on tests, but admits that at the moment her brain doesn't seem to be working. How would you set up and explain the problem to her?

7. On your first day of clinicals at a long-term care facility you are caring for a resident receiving total enteral feeding through a PEG tube. He is receiving 60 mL Jevity per hour as ordered when the pump fails and no other pumps are available. His over-extended regular nurse hangs drip tubing, adjusts the drip rate to something that "looks about right," and rushes on to her next demand. You decide to adjust the drip rate accurately to give the ordered amount. What do you need to know to do so?

8. Your hospice patient is on a double pump. One side is running NS at 30 cc/hr KVO, and the other has a 100 cc bag containing 2 mg morphine sulfate (MS) running at 5 cc/hr for pain management. She begins to show signs of breakthrough pain and her doctor orders 0.2 mg MS STAT. You would normally use a prefilled syringe containing 1 mg/1 mL MS and give 0.2 mL IV push, but on looking in the narcotic cabinet you find none available and the pharmacy is closed. It occurs to you that you could reset the pump to deliver 0.2 mg MS in 5 minutes, then go back to 5 mL/hr. At what rate should you set the pump?

9. A textbook on clinical calculations includes the following conversion for household to metric: 1 teaspoon = 5 mL = 5 g. As a home health nurse you need to help a client make homemade pediatric electrolyte solution using the following recipe: 1 L boiled water, 30 g sugar, 1.5 g salt, 2.5 g lite salt (KCl), 2.5 g baking soda. Since only kitchen measuring cups and spoons are available you need to convert from metric. The answer, according to the textbook, is 1 qt boiled water, 2 tbsp sugar, 1/4 tsp salt, 1/2 tsp lite salt, and 1/2 tsp baking soda. What questionable assumption does the textbook make?

10. In another textbook you are given the following example: The order is for Chloromycetin 300 mg IV bolus via saline lock. Label: Chloromycetin 1 g. Directions: Reconstitute with 10 mL sterile water for injection to yield 100 mg/mL. How may mL of Chloromycetin should be administered? Equivalents: 1 g = 10 mL, 1000 mg = 1 g 300 mg x 1000 mg 1g 1 g x 10 mL = 3 mL

While the answer "3" happens to be right, the set up is not. What error did the textbook make?

11. How would you prepare 2 L of 3% sodium hypochlorite (bleach) and water solution? You have only a measuring cup.

12. In a home setting, how would you prepare 1 L (or so) of normal saline (0.9% NaCl) using water and table salt if you have only a measuring cup and a teaspoon? On hand is an unopened 1 lb box of salt.

13. You have an order to infuse 1000 mL of D5W (5% Dextrose in water) IV over a period of 5 hr. No pump is available, but the tubing set package notes that the drop factor is 10 gtt/mL. How would you adjust the drip rate?

14. The order is for meperidine 60 mg and atropine gr 1/150, IM. The meperidine on hand is 100 mg/mL and the atropine is 0.4 mg/mL. The two are compatible so you plan to draw up both in the same syringe. How much of each will you draw up?

15. Tagamet is ordered 200 mg, IV, q6h. Available is Tagamet 300 mg in a 2 mL vial of aqueous solution. You are to dilute a portion of this in 100 mL NS and infuse over 20 minutes using a Buretrol with a drop factor of 60 gtt/mL. How much Tagamet will you inject into the Buretrol, and what will the drip rate be?

16. The order is for amoxicillin 60 mg, po, tid for a child weighing 13 lb. The pediatric dosage range is 20-40 mg/kg/day in three equal doses. Is the dose safe?

17. A child with severe poison ivy weighs 25 kg and Benadryl po 5 mg/kg/day is ordered q6h. Benadryl is available as a 12.5 mg/5 mL solution. What dose should be given?

18. You are to infuse heparin 5000 U in 250 mL NS at 30 mL/hr. What is the concentration of heparin solution? When you clear the pump you note that 187 mL have been infused. How much heparin has been given?

19. Your patient weighs 143 lb, and you are ordered to infuse 250 mg dobutamine in 500 mL NS at 10 mcg/kg/min. How many milligrams of dobutamine will infuse per hour?

20. Phenobarbital 180 mg/m2/24 hours given every eight hours is ordered for a child whose BSA (body surface area) is 0.29 m2. How much will each dose be?

21. You are to give Lidocaine 30 mcg/kg/min to a child weighing 55 lb. The piggyback contains 120 mg Lidocaine in 100 mL NS. At hat rate will you set the pump?

22. Nipride is ordered and you are to titrate to maintain the systolic blood pressure at 150 mm Hg. Available is Nipride 50 mg/250 mL. The range is 3-6 mcg/kg/min. A microdrip chamber (60 gtt/mL) is used with a pump. Your patient weighs 155 lb.

•

What is the concentration of the solution in mcg/mL?

•

How many mcg/min, lower and upper range, could be administered?

•

Within what range will the pump rate be set?

•

What is the titration factor in mcg/gtt?

•

The patient's systolic BP is currently 170 mm Hg while receiving the low range dose. If you increase the gtt/min by 5 gtt, how many mcg/min will the patient be receiving?

•

After 1 hr, the systolic blood pressure is 120 mm Hg, so you decrease the gtt/min by 6 gtt. How many mcg/min is the patient now receiving?

23. How would you prepare 500 mL of a 1:35 bleach solution from a 1:10 bleach solution using water?

24. Dr. Kissoff, wishing to test your perspicacity, orders 1.9 milliscruples of Morphine IV for each stone of body weight to be administered over a 300-minute period. Available is 1 gill of Morphine (MS) solution having a concentration of 0.4 pennyweights of Morphine dissolved in 1000 drachms of solution. The patient weighs 79 kilograms. At what rate should you set the pump? Your drug guide says that 0.8 to 10 mg of morphine can be given per hour. Is the ordered dose safe? (Yes, all the units of measure are real, if seldom used, but the point is you don't even have to know what the units are, just how to get from what you are given to what you want to know. See the long list of Conversion factors for clues, then use the Back button on your browser to return.)

25. You have come down with a bad case of the geebies, but fortunately your grandmother has a sure cure. She gives you an eyedropper bottle labeled: Take 1 drop per 15 lb of body weight per dose four times a day until the geebies are gone. Contains gr 8 heebie bark per dr 100 solvent. 60 drops=1 tsp. You weigh 128 lb, and the 4-oz bottle is half-full. You test the eyedropper and find there are actually 64 drops in a teaspoon. You are going on a three-week trip and are deeply concerned that you might run out of granny's geebie tonic. Do you need to see her before leaving to get a refill?

Go to top

**Abbreviations for Nursing Students
**

Units of Measure c cc cm dr dss fl ft g gal gl gr gt gtt in = = = = = = = = = = = = = = 2 cubic cup centimeters centimeters drams teaspoons fluid foot grams gallon glass grains drop drops inches

kg L lb m mcg mEq mg mL mm oz pt qt tbsp tsp U = unit Other Abbreviations a ABG ABT ac AD ADH ad ADA am AMA aq AS AU bid BP BUN c cap CAD CAT CBC CF CHF CNS CO COPD CPK CSF CVA CVP EC ECG EEG elix ext GFR GT h hct hgb

= = = = = = = = = = = = = =

kilograms liters pound meters micrograms milliquivalents milligrams milliliters millimeters ounce pint quart tablespoons teaspoons

= = = lib = = = = = = = = = = = = =

=

(ante) gas = antibiotic therapy before meals (ante cibum) right ear (auricula dexter) = antidiuretic hormone = as desired American Diabetes Ass. before noon (ante meridian) against medical advice = water left ear (auricula sinister) both ears (auriculi utro) twice a day (0900, 1700) = blood pressure blood urine nitrogen = with = capsule coronary artery disease computerized axial tomography complete blod count = cystic fibrosis congestive heart failure central nervous system = cardiac output chronic obstructive pulmonary disease = creatinine phosphokinase = cerebrospinal fluid = cerebrovascular accident central venous pressure = enteric coated = electrocardiogram = electroencephalogram = elixir = extract glomerulofiltration rate = gastrostomy = hour = hematocrit = hemoglobin arterial blood

=

before

hs ID ICP IM IV IVP IVPB KVO MI NG NJ NPO NS OD oint OTC OS OU p pc per pm po pr prn PT PTT q q1h q2h q3h q4h q6h q8h qd qh qid qod qs RBC ROM s sc sl sol sq SR ss S/S stat supp susp syr tab tid TO tr ung UTI

=

= = = =

=

(2100) intradermal = intracranial pressure = intramuscular = intravenous = intravenous push/pyelogram = intravenous piggyback = keep vein open = myocardial infarction = nasogastric = nasojejunal = nothing by mouth = normal saline = right eye (oculus dexter) = ointment = over the counter = left eye (oculus sinister) = both eyes (oculo utro) = after (post) = after meals (post cibum) = by = after noon (post meridian) = by mouth (per os) = per rectal = whenever necessary = prothrombin time = partial prothrombin time = every = every 1 hour = every 2 hours = every 3 hours every 4 hours (0900, 1300, 1700,...0500) every 6 hours (2400, 0600, 1200, 1800) every 8 hours (0600, 1400, 2200) = every day (0900) = every hour four times a day (0900, 1300, 1700, 2100) = every other day = quantity sufficient = red blood count = range of motion = without = subcutaneous = sublingual = solution = subcutaneous = sustained release = one half = signs and symptoms = immediately = suppository = suspension = syrup = tablet three times a day (0900, 1300, 1700) = telephone order = tincture = ointment = urinary tract infection

hour

of =

sleep,

bedtime

VO VS WBC = WNL = within normal limits

= = white

verbal vital blood

order signs count

Go to top

**Conversion Factors for Nursing Students
**

Short list

1 cup (c) = 1 dram (dr) = 1 dram (fl dr) 1 gallon (gal) = 1 glass = 1 grain (gr) = 1 gram (g) = 1 inch (in) = 1 kilogram (kg) = 1 liter (L) = 1 milliliter (mL) 1 minim = 1 ounce (oz) = 1 ounce (oz) = 1 ounce (fl oz) = 1 pint (pt) = 1 pound (lb) = 1 quart (qt) = 1 quart (qt) = 1 tablespoon (tbsp) = 1 teacup = 1 teaspoon (tsp) = 4.93 mL 8 60 = 4 8 64.8 15.43 2.54 2.2 1.057 = 1 2 8 29.57 16 16 0.946 2 3 6 ounces grains 60 quarts ounces milligrams grains centimeters pounds quarts 16.23 drop tablespoons drams milliliters ounces ounces liters pints teaspoons ounces (oz) (gr) minims (qt) (oz) (mg) (gr) (cm) (lb) (qt) minims (gt) (tbsp) (dr) (mL) (oz) (oz) (L) (pt) (tsp) (oz)

Long list

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 cental = centimeter (cm) = cubic centimeter (cc) cup (c) = drachm = dram (dr) = dram (fl dr) gallon (gal) = gill = glass = grain (gr) = gram (g) = gram (g) = gram (g) = hand = inch (in) = kilogram (kg) = kilogram (kg) = 45,359 10 = 1 8 3.55 60 = 4 4 8 64.8 1,000 1,000,000 15.43 4 2.54 1,000 2.2 grams millimeters milliliter ounces milliliter grains 60 quarts ounces ounces milligrams milligrams micrograms grains inches centimeters grams pounds (g) (mm) (mL) (oz) (mL) (gr) minims (qt) (oz) (oz) (mg) (mg) (mcg) (gr) (in) (cm) (g) (lb)

1 liter (L) 1 liter (L) 1 meter (m) 1 meter (m) 1 milligram (mg) 1 milliliter (mL) = 1 milliliter (mL) 1 milliliter (mL) 1 minim = 1 ounce (fl oz) 1 ounce (oz) 1 ounce (oz) 1 ounce (oz) 1 ounce (oz) 1 ounce (oz) 1 ounce, fluid (fl 1 palm = 1 pennyweight (dwt) 1 pint (pt) 1 pint (pt) 1 pound (lb) 1 pound (lb) 1 quart (qt) 1 quart (qt) 1 scruple = 1 stone 1 tablespoon (tbsp) 1 teacup = 1 teaspoon (tsp) 1 teaspoon (tsp) = 4.93 mL

= = = = = 1 = = = = = = oz) = = = = = = = =

1000 milliliters 1.057 quarts 1,000 millimeters 100 centimeters 1,000 micrograms cubic centimeter 15 drops = 16.23 1 drop 2 tablespoons 20 pennyweights = 24 31.1 grams 480 grains 8 drams = 29.57 milliliters 3 inches 24 grains 16 ounces = 4 16 ounces = 350 0.946 liters 2 pints 20 grains 0.14 3 teaspoons 6 ounces 60 drops

(mL) (qt) (mm) (cm) (mcg) (cc) (gt) minims (gt) (tbsp) (dwt) scruples (g) (gr) (dr) (mL) (in) (gr) (oz) gills (oz) scruples (L) (pt) (gr) centals (tsp) (oz) (gtt)

Go to top

Appendix A

**Fun with Dimensional Analysis
**

Dimensional analysis (also known as the factor-label method) is by far the most useful math trick you'll ever learn. Maybe you've learned some algebra, but do you ever use it? Ever foresee using it? For most people the answer is "not after the final exam." For a fraction of the effort needed to learn algebra, you too can learn "dimensional analysis." First off, however, let's get rid of the big words. What this is all about is just conversion-converting one thing to another. This is something you will have occasion to do in real life. This is seriously useful stuff. This trick is about applied math, not about numbers in the abstract. We're talking about measurable stuff you can count or measure. Anything you measure will have a number with

some sort of "unit of measure" attached. A unit could be miles, gallons, miles per second, peas per pod, or pizza slices per person. First a little test of basic math: Which of the following statements are True? 1. 20/48 = 5/12 2. 16/5 = 3 1/5 3. 1 7/8 = 15/8 4. 2/3 + 3/4 = 19/12 5. 5/9 + 2/3 = 1 2/9 6. 10 1/5 - 6 3/5 = 3 3/5 7. 7 1/8 x 3/4 = 5 11/32 8. 5/8 ÷ 1/16 = 10 9. 35% = 0.35 10. xiv = 14

All are true except #4, which should be 17/12. If you missed any, review: 1. 2. 3. 4. 5. 6. Reducing to lowest terms Changing an improper fraction to a mixed number Changing a mixed number to an improper fraction Finding a common denominator Addition of fractions Subtraction of fractions

7. Multiplication of fractions 8. Division of fractions 9. Percent 10. Roman numerals (Click back button to go back to test if you are taking it)

Go to top

**25 Examples (To take as a test first, click Med-math Practice problems)
**

1. How many seconds are in a day? Okay, so this is not a med-math problem, but as an introduction to dimensional analysis (DA), it works fine. If you're up to speed in DA, skip this answer. Otherwise, what do you do? First, as with all DA problems, don't panic. If you have no idea what the answer is or how to come up with an answer, that's fine because you're not going to solve THE problem. What you are going to do is break the problem down into several small problems that you can solve, and here's how. a. Ask yourself, "What units of measure do I want to know or have in the answer?" In this problem you want to know "seconds in a day." After you figure out what units you want to know, translate the English into Math. Math is a sort of shorthand language for writing about numbers of things. If you can rephrase what you want to know using the word "per," then that's a step in the right direction, so rephrase "seconds in a day" to "seconds per day." In math terms, what you want to know is:

b. Ask, "What do I know?" What do you know about how "seconds" or "days" relate to other units of time measure? You know that there are 60 seconds in a minute. You also know that in 1 minute there are 60 seconds. These are two ways of saying the same thing. You know that there are 24 hours in a day (and in one day there are 24 hours). If you could now connect "hours" and "minutes" together you would have a sort of bridge that would connect "seconds" to "days" (seconds to minutes to hours to days). The connection you need, of course, is that there are 60 minutes in an hour (and in one hour there are 60 minutes). When you have this kind of connection between units, then you know enough to solve the problem--but first translate what you know into math terms that you can use when solving the problem. If in doubt, write it out:

All of these statements, or conversion factors, are true or equivalent (60 seconds = 1 minute). All you need to do now is pick from these statements the ones that you actually need for this problem, so.... c. Ask, "From all the factors I know, what do I need to know?" Remember that you want to know:

So pick from the things you know a factor that has seconds on top or day(s) on the bottom. You could pick either of the following two factors as your "starting factor:"

Write down your starting factor (say you pick 60 seconds per 1 minute):

Now the trick is to pick from the other things you know another factor that will cancel out the unit you don't want. You start with "seconds" on top. You want "seconds" on top in your answer, so forget about the seconds--they're okay. The problem is you have "minutes" on the bottom but you want "days." You need to get rid of the minutes. You cancel minutes out by picking a factor that has minutes on top. With minutes on top and bottom, the minutes will cancel out. So you need to pick 60 minutes per 1 hour as the next factor because it has minutes on top:

You now have seconds per hour, since the minutes have cancelled out, but you want seconds per day, so you need to pick a factor that cancels out hours:

d. Solve it. When you have cancelled out the units you don't want and are left only with the units you do want, then you know it's time to multiply all the top numbers together, and divide by all the bottom numbers.

In this case you just need to multiple 60x60x24 to get the answer: There are 86,400 seconds in a day.

Here's how this problem might look if it were written on a chalkboard:

Remember that you don't need to worry about the actual numbers until the very end. Just focus on the units. Plug in conversion factors that cancel out the units you don't want until you end up with the units you do want. Only then do you need to worry about doing the arithmetic. If you set up the bridge so the units work out, then, unless you push the wrong button on your calculator, you WILL get the right answer every time.

2. You are to give "gr 5 FeSO4" but the available bottle gives only the milligrams of iron sulfate per tablet (325 mg/tab). How many milligrams is the order for? To get from grains to milligrams you'll need a conversion factor like 1 gr = 64.8 mg. 5 gr x 64.8 mg = 324 mg, so you decide that's close enough and give 1 tab. 1 gr Rounding to 60 mg/1 gr, as is often done, gives 300 mg as your answer, which might cause you to doubt if you will be giving the ordered dose.

3. You just opened a 500 mL bottle of guaifenesin and will be giving 1 tablespoon per dose. How many doses are in the bottle? In other words how many tablespoons are in 500 mL? 500 mL x 4.93 mL 3 tsp 1 tsp x 1 tbs = 33 tbs

Rounding to 5 mL gives you the same answer, so rounding to 5 mL is reasonable.

4. You give your home health patient an unopened 500 mL bottle of guaifenesin and tell them to take 2 teaspoons 4 times a day as ordered. They ask you how long the bottle will last.

You could give an answer in hours or weeks, but you figure "days" is the better choice for an answer unit. Your set up:

500

mL x 1 5 mL 2 tsp

tsp x 4 doses

1

dose

x

1

day

=

12.5

days,

so you tell them the bottle will last 12 days.

5. Your order is for meperidine (Demerol) 35 mg, IM, STAT. Available is a 2 mL vial containing 50 mg/mL meperidine. On hand are 1 cc and 3 cc syringes. How much should you draw up into which syringe? Your answer will be in mL (cc), the number of milliliters that will contain 35 mg meperidine. You know from the label that there is 50 mg meperidine in 1 mL of meperidine solution. You realize you will give less than 1 mL. Your set up: 35 mg mep. x 50 mg mep. 1 mL mep. sol = 0.7 mL mep. sol

or, since you know that you want "mL on top" in your answer, you could start with 1 mL/50 mg: 1 50 mg mL x 35 mg = 0.7 mL

If you don't actually write down full labels, at least be thinking "mL of what?" "mg of what?"

6. You are shadowing a nurse during a clinical who receives an order to adjust the infusion rate of a pump so that 1.6 mg of lidocaine are being delivered per minute. Hanging is a 100 cc piggyback containing 0.4 grams lidocaine, a 0.4% solution. Without writing anything down, the nurse tries to solve the problem on a calculator. After the fifth different and incorrect answer you find a piece of scratch paper and offer to show her how to set up the problem. She assures you she can always do problems like this on tests, but admits that at the moment her brain doesn't seem to be working. How would you set up and explain the problem to her? We want to know mL/hr, which has "time" on the bottom so starting with 1.6 mg/min should work. We now just have to change minutes to hours, and get from mg to mL. 1.6 mg 1 min L. x 60 min 1 hr 400 mg L. x 100 hr mL L. sol = 24.0 mL L. sol

Checking to make sure all the units of measure, except for mL and hr, cancel out, now is the time for the calculator. Crunching the numbers twice (first x x x ÷ ÷ , then x x ÷ x ÷ ) and getting 24.0 each time, we can now set the pump with confidence.

7. On your first day of clinicals at a long-term care facility you are caring for a resident receiving total enteral feeding through a PEG tube. He is receiving 60 mL Jevity per hour as ordered when the pump fails and no other pumps are available. His over-extended regular nurse hangs drip tubing, adjusts the drip rate to something that "looks about right," and rushes on to her next demand. You decide to adjust the drip rate accurately to give the ordered amount. What do you need to know to do so? You look in the trash for the tubing package, but don't see it. You recall seeing tubing in the supply room and go there looking for the same tubing as what was hung. The reason is drop size varies from 10 to 60 drops per mL. The manufacture would have calibrated their drip chamber and put the number of drops/mL on the package, and it is the drop factor (drops/mL) that you need to know. You finally find the tubing used and the package says 12 drops/mL. Your answer will be in drops/min, so: 60 1 hr mL 1 mL x 12 60 min drops min x 1 hr = 12 drops

or 3 drops every 15 seconds which is easier to count. It turns out that "about right" was about twice the ordered rate. 8. Your hospice patient is on a double pump. One side is running NS at 30 cc/hr KVO, and the other has a 100 cc bag containing 2 mg morphine sulfate (MS) running at 5 cc/hr for pain management. She begins to show signs of breakthrough pain and her doctor orders 0.2 mg MS STAT. You would normally use a prefilled syringe containing 1 mg/1 mL MS and give 0.2 mL IV push, but on looking in the narcotic cabinet you find none available and the pharmacy is closed. It occurs to you that you could reset the pump to deliver 0.2 mg MS in 5 minutes, then go back to 5 mL/hr. At what rate should you set the pump? Again you want mL/hr, so start with mL on top: 100 mL MS sol x 2.0 mg MS 5 min 0.2 mg 1 hr MS x hr 60 min = 120 mL MS sol

Now that you know the rate, you need the volume to be infused: 100 mL 2.0 mg MS MS sol x 0.2 mg MS = 10 mL MS sol

Just to double check, how many minutes will it take for the pump to deliver 10 mL at 120 mL/hr? 60 1 hr min 120 mL x 1 hr x 10 mL = 5 min

9. A textbook on clinical calculations includes the following conversion for household to metric: 1 teaspoon = 5 mL = 5 g. As a home health nurse you need to help a client make homemade pediatric electrolyte solution using the following recipe: 1 L boiled water, 30 g sugar, 1.5 g salt,

2.5 g lite salt (KCl), 2.5 g baking soda. Since only kitchen measuring cups and spoons are available you need to convert from metric. The answer, according to the textbook, is 1 qt boiled water, 2 tbsp sugar, 1/4 tsp salt, 1/2 tsp lite salt, and 1/2 tsp baking soda. What questionable assumption does the textbook make? While 1 tsp = 5 mL is a valid conversion factor, 1 tsp = 5 g is valid only when measuring water. "Teaspoon" is a measure of fluid volume and not weight. Since water has a density of 1 (1 g/1 cc), 1 tsp of water would weigh 5 grams. The density of salt, however, is 2.2 g/cc (sugar 1.6, KCl 2.0, NaHCO3 2.2), so a teaspoon would weight over twice as much, right? But wait, these densities are for the solid substances. In powdered form they would weigh less. A teaspoon of salt (density 1.3 g/cc) would weigh 6.5 grams. The density of granulated sugar is 0.7 g/cc, KCl is 1.0 g/cc, and baking soda is 0.8 g/cc, so a teaspoon of each would actually weigh between 3.5 g/cc and 6.5 g/cc. Assuming 5 g/tsp for each seems a bit rough. To do the conversions right, factor in the density: Sugar: 30 g x 1 cc x 1 mL x 1 tsp x 1 tbsp = 2.9 tbsp (not 2.0 tbsp) 0.7 g 1 cc 5 mL 3 tsp Salt: 1.25 g 1.3 g x 1 5 mL mL x 1 tsp = 0.2 tsp (close to 1/4 tsp)

Baking soda: 2.5 g x 1 mL x 1 tsp = 0.63 tsp (closer to 2/3 than 1/2) 0.8 g 5 mL KCl, with density 1, remains at 1/2 tsp. Does taking the density into account really matter? Realizing that density is something to take into account matters, and until you look up the densities and factor them in you wouldn't know if it matters or not.

10. In another textbook you are given the following example: Order: Chloromycetin 300 mg 1V bolus via saline lock. Label: Chloromycetin 1 g. Directions: Reconstitute with 10 mL sterile water for injection to yield 100 mg/mL. How may mL of Chloromycetin should be administered? Equivalents: 1 g = 10 mL, 1000 mg = 1 g 300 mg x 1000 mg 1 g 1 g x 10 mL = 3 mL

While the answer "3" happens to be right, the set up is not. What error did the textbook make? The set up is in error due to a failure to fully label units. The 10 mL is "10 mL sterile water." You have to ask, "10 mL of what?" Your answer unit, what you want to know, is "mL Chloromycetin sol" and not just "mL." You can't use "mL water" and end up with "mL Chlor. sol." When you add 10 mL water to reconstitute you will end up with somewhat more than 10 mL Chlor. solution. Since you want "mL Chlor. sol" in your answer, pick a factor that has "mL Chlor. sol" in it and in the right place. You are given "100 mg/mL" which should be more completely written as "100 mg Chlor./mL Chlor. sol" and "10 mL/g" should be "10 mL water/1 g Chlor." which is quite an unnecessary bit of information for solving this problem, though the text incorrectly uses it.

300

mg

Chlor. x 1 g Chlor. x 1000 mg Chlor. 1 g Chlor.

10

mL

water

=

3

mL

water

(not!)

The correct set up should be: 300 mg Chlor. x 1 100 mg Chlor. mL Chlor. sol = 3 mL Chlor. sol

11. How would you prepare 2 L of 3% sodium hypochlorite (bleach) and water solution? You have only a measuring cup. 2 L sol x 1000 mL x 3 mL bleach x 1 oz 1L 100 mL sol 30 mL 8 oz But how much water? The solution is 97% water, right? 2 L sol x 1000 mL x 97 mL water x 1 oz 1L 100 mL sol 30 mL 8 oz x 1 cup = 8.1 cups water x 1 cup = 1/4 cup bleach

12. In a home setting, how would you prepare 1 L (or so) of normal saline (0.9% NaCl) using water and table salt if you have only a measuring cup and a teaspoon? On hand is an unopened 1 lb box of salt. The key is to clearly understand what 0.9% means. Salt is measured by weight, so 0.9% means 0.9 parts salt by weight to 100 parts salt solution (not water) by weight. If you knew the density of granulated salt you could convert from a desired weight of salt to a volume of salt. Since you can only measure volume (using cup and tsp), you will somehow have to determine the density of salt. You could look up the density, or what if you poured the box of salt (16 oz) into your measuring cup? Doing so you find that you have a bit over 12 fluid ounces of salt. Recalling that density is weight/volume, you figure the density of salt at 16 oz/12.3 fl oz or 1.3 oz/fl oz. What you want to know is the number of teaspoons per quart. The set up follows: 12.3 fl oz salt x 0.9 oz salt 16 oz salt 100 oz salt sol 1 qt x 32 oz x 2 tbsp x 3 tsp = 1 1/3 tsp salt 1 fl oz 1 tbsp qt salt sol

To make one quart you would first put the salt into a measuring cup then fill to the 1 quart mark.

13. You have an order to infuse 1000 mL of D5W (5% Dextrose in water) IV over a period of 5 hr. No pump is available, but the tubing set package notes that the drop factor is 10 gtt/mL. How would you adjust the drip rate? First, what do you want to know? The flow rate in gtt/min, which are the answer units. What do you know? You're given that there are 10 gtt/mL and that the infusion rate is 1000 mL/5 hr.

Since you want gtt on top and 10 gtt/mL has gtt in the right place, 10 gtt/mL makes a perfectly good starting factor--from there you just need to get from mL to min. The set up then: 10 1 mL gtt 5 hr x 1000 60 min min mL x 1 hr = 33 gtt

You wouldn't want to count a full minute, so divide by 3 and count for 20 seconds. 14. The order is for meperidine 60 mg and atropine gr 1/150, IM. The meperidine on hand is 100 mg/mL and the atropine is 0.4 mg/mL. The two are compatible so you plan to draw up both in the same syringe. How much of each will you draw up? For both you want to know mL, your answer unit. 60 1 150 mg 100 mg x 1 mg mL x 1 = mL 0.6 = mL 1.1 mL meperidine atropine

gr x 64.8 1 gr 0.4 mg

15. Tagamet is ordered 200 mg, IV, q6h. Available is Tagamet 300 mg in a 2 mL vial of aqueous solution. You are to dilute a portion of this in 100 mL NS and infuse over 20 minutes using a Buretrol with a drop factor of 60 gtt/mL. How much Tagamet will you inject into the Buretrol, and what will the drip rate be? You want to know mg of Tagamet, and gtt/min. 200 mg T. 100 mL NS 300 mg T. The drip rate would be: 60 1 mL gtt x 20 min 101.3 mL min T. sol = 304 gtt T. sol x 2 100 mL NS mL T. sol = 1.3 mL T.

Can you count 5 gtt/sec? Not likely, so what do you do? What if you added a secondary set with a drop factor of 12 gtt/mL? 12 1 mL gtt x 20 min 101.3 min mL T. sol = 60 gtt T. sol

16. The order is for amoxicillin 60 mg, po, tid for a child weighing 13 lb. The pediatric dosage range is 20-40 mg/kg/day in three equal doses. Is the dose safe? You want to know mg/kg/day for this child. What you know is that you will give 60 mg per 13 lb body weight per dose or 60 mg/13 lb/dose, which true but is unusable in this form, so you rewrite

it as 60 mg/13 lb x 1 dose. How can you do that? Consider dividing 1/4 by 2. Half of one quarter is one eighth, but how to figure that: 1 4 2 = 4 1 2 x 1 4 = x 1 2 = 1 8

Dividing by 2 is the same as inverting 2 to get 1/2 and multiplying. Acceleration, to give another example, is measured in feet per second per second or ft/sec/sec, which is equal to ft/(sec x sec) or ft/sec2.

60 mg x 2.2 lb x 3 dose = 30.5 mg 13 lb x 1 dose 1 kg 1 day kg x day

= 30.5 mg/kg/day--a safe dose.

Whenever you have x per y per z, rearrange in the form x/y*z and everything will stay straight. 17. A child with severe poison ivy weighs 25 kg and Benadryl po 5 mg/kg/day is ordered q6h. Benadryl is available as a 12.5 mg/5 mL solution. What dose should be given? You want to know mL/dose. Since you want mL on top, start with: 5 mL x 5 mg 12.5 mg kg x day 4 doses x 1 day dose x 25 kg = 12.5 mL

18. You are to infuse heparin 5000 U in 250 mL NS at 30 mL/hr. What is the concentration of heparin solution? When you clear the pump you note that 187 mL have been infused. How much heparin has been given? You want to know Units/mL, so nothing tricky here: 5000 250 mL 187 mL mL sol U sol x = 20 U 20 = 74,800 U/mL U

19. Your patient weighs 143 lb, and you are ordered to infuse 250 mg dobutamine in 500 mL NS at 10 mcg/kg/min. How many milligrams of dobutamine will infuse per hour? You want to know mg/hr, which has time on the bottom. After converting to 10 mcg/kg x min you note that time is also on the bottom, so this should work as a starting factor: 10 mcg x 60 min x 1 mg kg x min 1 hr 1000 mcg 2.2 lb x 1 kg hr x 143 lb = 39 mg

20. Phenobarbital 180 mg/m2/24 hours given every eight hours is ordered for a child whose BSA (body surface area) is 0.29 m2. How much will each dose be? You want to know mg/dose, so you could start with 1 day/3 doses or 180 mg/m2/day: 1 day x 3 doses m2 x day 180 mg dose x 0.29 m2 = 17.4 mg

21. You are to give Lidocaine 30 mcg/kg/min to a child weighing 55 lb. The piggyback contains 120 mg Lidocaine in 100 mL NS. At what rate will you set the pump? You want to know mL/hr. Starting with the patient's weight usually works out: 55 lb x 1 kg x 30 mcg x 1 mg x 100 mL x 60 min = 37.5 mL 2.2 lb kg x min 1000 mcg 120 mg 1 hr hr

22. Nipride is ordered and you are to titrate to maintain the systolic blood pressure at 150 mm Hg. Available is Nipride 50 mg/250 mL. The range is 3-6 mcg/kg/min. A microdrip chamber (60 gtt/mL) is used with a pump. Your patient weighs 135 lb. Titration problems are just longer, not more difficult, so relax and focus on what you want to know.

•

What is the concentration of the solution in mcg/mL?

**Here you want mcg/mL, so: 50 250 mL
**

•

mg 1 mg

x

1000

mcg

=

200

mcg/mL

How many mcg/min, lower and upper range, could be administered? 1 kg x min 135 lb = 184 mcg low range

3 mcg x kg x min 2.2 lb

**Since the high range is twice the low, just multiple by 2 to get 368 mcg/min.
**

•

Within what range will the pump rate be set?

What's the low and high rate the pump could be set at in mL/hr? 184 mcg x 60 min x 1 min 1 hr 200 mcg hr 1 mL = 55 mL low range,

which

is

also

55

gtt/min: 55 mL x 1 hr 60 min 1 mL

1

hr min

x

60

gtt

=

55

gtt

You could plug in 368 for 184 and recalculate, or again just double 55 to get 110 mL/hr for the upper range.

•

What is the titration factor in mcg/gtt for the low range?

Don't know what a titration factor is? It don't matter 'cause you know you want mcg/gtt: 184 1 min

•

mcg 55 gtt

x gtt

1

min

=

3.3

mcg

The patient's systolic BP is currently 170 mm Hg while receiving the low range dose. If you increase the gtt/min by 5 gtt, how many mcg/min will the patient be receiving?

**You want mcg/min and from the above, going from 55 to 60 gtt/min: 3.3 1 gtt
**

•

mcg 1 min

x min

60

gtt

=

198

mcg

After 1 hr, the systolic blood pressure is 120 mm Hg, so you decrease the gtt/min by 6 gtt. How many mcg/min is the patient now receiving?

You again want mcg/min and are going from 60 to 54 gtt/min: 3.3 1 gtt mcg 1 min x min 54 gtt = 178 mcg

23. How would you prepare 500 mL of a 1:35 bleach solution from a 1:10 bleach solution using water? You want to know how much concentrated bleach solution (mL c.b.) you need to make the weaker solution (mL w.b.). 10 mL 1 mL b. c.b. x 1 35 mL w. b. mL b. x 500 mL w.b. = 143 mL c.b.

To the 143 mL of concentrated bleach solution you would add enough water to make 500 mL 1:35 solution. If you fully label all amounts, you should avoid confusion.

24. Dr. Kissoff, wishing to test your perspicacity, orders 1.9 milliscruples of Morphine IV for each stone of body weight to be administered over a 300-minute period. Available is 1 gill of Morphine (MS) solution having a concentration of 0.4 pennyweights of Morphine dissolved in 1000 drachms of solution. The patient weighs 79 kilograms. At what rate should you set the pump? Your drug guide says that 0.8 to 10 mg of morphine can be given per hour. Is the ordered dose safe? (Yes, all the units of measure are real, if seldom used, but the point is you don't even

have to know what the units are, just how to get from what you are given to what you want to know. See the long list of Conversion factors for clues, then use the Back button on your browser to return.)

Breaking the problem down stepwise: As always, start by asking what do you want to know? If you've worked with IV pumps you know they are programmed in mL/hr, so your answer will have to be in these units of measure. What do you know? From the problem you know the patient weighs 79 kg, and that you are to infuse 0.0019 scruples per stone per 300 minutes (it helps to rephrase the problem using the word "per"). You are also told that there are 0.4 pennyweights MS per 1000 drachms and that you have a whole gill of this solution however much a gill is. You also know that since you need "hours" in your answer you will need to get from minutes (300 minutes) to hours at some point. And everyone knows that in 1 hour there are 60 minutes and in 60 min. there is 1 hr. (or in math terms you know 60 min/1 hr, and 1 hr/60 min). The rest of what you need to know will have to be looked up. Doing so you find that there are 4 ounces per gill, 20 grains per scruple, 24 grains per pennyweight, and 3.55 milliliters per drachm. Looking up "stone" you find that there are 0.14 centals per stone, which forces you to lookup "cental" where you find that there are 45.36 kilograms per cental. 3. Setup: What factor should you start with? Since you know that the patient's weight is a determining factor, you could start with it. Or, since you know your answer has to be in mL/hr, you know "hours" has to be on the bottom, so 60 min/1 hr would be a logical starting factor (you would then just have to get from "min" to "mL"). Or, since you want "mL" on top, 3.55 mL/drachm would also be a logical starting factor. If you recall the Commutative Law of Multiplication, you realize you get the same answer no matter what order you multiply (or divide) your terms in, but you decide to pick 79 kg as your starting factor. 79 kg x 1 cental x 1 stone x 0.0019 scruples x 60 min x 20 grains x 1 pennyweight x 1000 drachms x 3.55 mL = ? mL 45.36 kg 0.14 centals 1 stone x 300 min 1 hr 1 scruple 24 grains 0.4 pennywts 1 drachm hr Does everything cancel out except for "hr" and "mL"? Bingo, punch the numbers in (correctly) and you got it: 35 mL/hr. Does the answer make sense? The flow rate is within usual limits, but is the dose safe? Go back to step 1: you'll need to know mg/hr, your answer unit, and you'll need a conversion factor to get from grains to milligrams. Since you need "hr" on the bottom, start with 35 mL/hr. 35 mL x 1 drachm x 0.4 pennyweights x 24 grains 1 hr 3.55 mL 1000 drachms 1 pennyweight 1 grain x 64.8 mg = 6.1 mg hr

The dose is safe, but on the high side, so you'll be monitoring your patient closely. Oh, and since you have 1 gill (4 ounces) or about 120 mL of morphine solution, are you going to have enough? Go figure. 25. You have come down with a bad case of the geebies, but fortunately your grandmother has a sure cure. She gives you an eyedropper bottle labeled: Take 1 drop per 15 lb of body weight per dose four times a day until the geebies are gone. Contains gr 8 heebie bark per dr 100 solvent. 60 drops=1 tsp. You weigh 128 lb, and the 4-oz bottle is half-full. You test the eyedropper and find there are actually 64 drops in a teaspoon. You are going on a three-week trip and are deeply concerned that you might run out of granny's geebie tonic. Do you need to see her before leaving to get a refill? Now this one is a bit hard if you haven't been paying close attention. First, what do you want to know? You want to know how long the bottle will last. You could figure out days/bottle or weeks/bottle and see if the bottle will last longer than 3 weeks or 21 days. So you write down "Answer units = days/bottle" What do you know to start off with that you might need to know? You write down the following:

You realize that if a 4-oz bottle is half-full, then there is 2 oz of tonic in it, but you could figure it out dimensionally if you wanted to:

You would then end up with "days/half-bottle" in your answer, but it's easier to just go with 2 oz/bottle. What should you use as a starting factor? You pick 128 lb because it's something you're given and starting with weight usually works. You set the problem up:

Houston, we have a problem. You ended up with units reversed from what you wanted. You figured out how much of the bottle you would use in one day. What to do? You could hit the 1/x button on your calculator if it had one, or invert the answer by dividing 1 by 0.044, or start over with 128 lb on the bottom. What? Can you do that? Sure you can. You could even put 128 lb on the end and on the bottom, or put it in the middle somewhere. You decide to start over, this time picking a starting factor that already has "day" or "bottle" in the right place.

So, it looks like you'll have enough. At some point you need to know how many drops per dose you will need to take, so you figure it out:

As a practical matter, you can't take 8.533 drops per dose; you have to round off. At this point you realize that when you calculated 22.5 days/bottle, you were not figuring on 9 drops/dose. You decide to recalculate to see if rounding up to 9 makes a significant difference.

You note a small difference, but conclude that you have just enough geebie tonic. Concluding that you have enough, however, and having enough may not be the same thing. The story continues: You leave on your trip and on the 19th day you run out of geebie juice. You didn't spill any, and no one took any. You sit in a stunned stupor trying to figure out where you went wrong in your calculations. You finally realize there might not have been 2.0 oz of tonic in the bottle to begin with. A measurement like "half a bottle" should not inspire great certainty. You wish you had measured the amount and found that the bottle contained 2.0 + 0.05 oz of tonic, but what you were given, more or less, was that you had 2 + 0.5 oz of tonic. There could be anything from 1.5 to 2.5 oz in the bottle. Recalculating using the low and high values, you find you had enough tonic to last somewhere between 16 and 26 days. If you had figured out the correct answer of 21 + 5 days the first time, you would have realized you had only slightly less than a 50/50 chance of running out, and would have gone to see Granny for a refill.

Go to top

Summary

•

Don't panic. Break THE PROBLEM down into small ones you CAN solve.

• •

•

• • • •

Figure out what answer unit(s) you want to end up with. This is usually easy. Write down, in math terms, everything you know that relates to the problem. You may need to read the problem several times, rephrasing parts of it, so you can translate everything into math terms. You may need to look up a few conversion factors, but that's inconvenient, not difficult. You now need to pick a starting factor. If possible pick one that already has one of the units you want in the right place. Otherwise start with something you are given that is not a conversion factor. Plug in conversion factors that allow you to cancel out any units you don't want until you are left with only the units you do want (your answer units). If you can't solve the problem, pick a different starting factor and start over. Do the math and solve it. Now double-check your calculations. Ask yourself if the answer seems right or reasonable. If not, recheck everything.

Go to top

Appendix B

Go to top

**A Critique of Clinical Calculations: A unified approach, 4th ed.
**

The steps for doing dimensional analysis are given in the textbook as: 1. Determine the starting factor and answer unit. 2. Formulate a conversion equation. 3. Solve the conversion equation. Determining the answer unit or units is crucial; they are not always obvious and can be challenging to determine. For some problems, reading the problem correctly is the only challenge. Students need to be able to translate sometimes convoluted English descriptions of a problem into clear, properly labeled factors they can later use to solve the problem. This skill is not emphasized in the textbook. If the answer unit is always given in the examples used, then this is because the examples have been contrived to be more simple and consistent than actual problems tend to be. In some real-world problems no starting factor is given, or several possible starting factors are given with no way to decide, initially, which to use. It is preferable, in such cases, to determine everything you know that might be relevant to solving the problem, then decide, after the answer unit is determined, which of the factors you know would make an appropriate starting factor.

All examples used throughout the text use only numbers having a single unit attached for starting factors. Apparently "1 hour" is an acceptable starting unit, but "250 mL/hour" is not. This is not correct as starting factors are often in the form of "something per something." Indeed, some problems cannot be solved if they have a single unit starting factor (see example 3 in Appendix A). While many conversion factors are approximations, and fraction of a percent errors are unimportant in medication math, 10 percent errors are a bit worrisome. Equating 1 grain with 60 milligrams when the actual equivalency is closer to 64.8 mg, is questionable, as is equating liters and quarts, or 1 mL to 15 minims (actually 1 mL = 16.23 minims). It is possible to solve a problem and come up with answers that differ by as much as 10% depending on which approximate conversion factors you decide to use. If + 5% errors are acceptable, then, as an aside, any answer to a test question that is within 5% of the correct answer should be counted as correct. It is oddly inconsistent to insist on carrying out calculations to two decimals, rounding to the nearest tenth, when far greater errors can be introduced by using loose approximations. When, in chapter 6, a problem involving amount/body weigh/day comes up, the solution is presented in an unorthodox way. The problem (p. 49) gives 25 mg/kg/24 hr. When doing dimensional analysis it is essential that all the units given should be used and accounted for. Ignoring a given unit, then pulling it out of thin air at the end is poor technique, yet this is what the textbook does. The solution is given as:

The problem is that the correct answer units should be how many mL should be administered per day, or "mL/day." Omitting the "per day" part doesn't alter the fact that that is what you want to know--not per hour, not per dose, but per day. There is actually a simple rule that applies here. For example, when acceleration is measured in feet per second per second, it is not written as ft/sec/sec, but as ft/sec2 because ft/sec/sec is equal to ft/sec x sec. So if you're given mg/kg/day, the preferred way to deal with such a "triple decker" is to rewrite it as mg/kg x day. In this form it can be used, all undesired units cancel, and you end up with the desired answer with the right units attached:

If the problem called for "mL/dose" given 4 doses per day, then the solution is straightforward:

If "day" were omitted, however, this problem would become more difficult to solve. The textbook method is to calculate "mL," then divide by 4 to get "mL/dose." Students must remember to perform this final "critically important" step which would not exist if better technique were used. As the text acknowledges, "it is easy to forget to divide the total daily dose into the prescribed number of doses, thus greatly increasing the risk of administering an overdosage (sic)."

Problems of this sort are common, and it is unfortunate that the authors neglect to show students how to logically deal with them. The risk of confusing some students by introducing a new rule can hardly be worth the risk of error introduced by teaching a flawed technique. In Chapter 10, page 184, an example is shown, as a model for students to follow, to determine how many mcg/min must be administered to a 215 lb patient at 3 mcg/kg/min:

In this example, at least, minutes are not omitted then added at the end, and the technique is not even erroneous, but merely confusing to many students and visually awkward. A student might try to logically extend this technique to determine mL/hr:

The student who notices that the answer doesn't make sense might wonder what went wrong. Would they realize that when "mcg" was cancelled that "3 1/min" was left requiring the use of 60 min/1 hr instead of 1 hr/60 min? Trying to explain how to work around the poor technique employed by this example only digs a deeper hole. The better response to student confusion would be to have them put a big X mark over this section of the textbook and show them a sensible way to set it up:

Another case of flawed technique arises in Chapter 10. Students are given problems that require converting from mL/hr to gtt/min, and are shown conversion equations like the following:

The problem, again, is that the correct answer unit is "gtt/min" and not "gtt" as it appears. The correct answer is just pulled out of nowhere and declared to be "33 gtt/min." The initial starting factor of "1 min" is spurious. It is not a given, and it means absolutely nothing to say that you know "1 min" or "1 hour" or "1 cabbage." If such meaningless starting factors are simply omitted from such examples, the problems are perfectly setup to yield the correct answers with the correct answer units. It seems that the pseudo-starting factor is used to avoid having a starting factor with more than one unit attached. As mentioned, however, there is no such requirement when doing dimension analysis. In the above example "90 mL/1 hr" would make a logical and perfectly good starting factor. Students should be told to just ignore the nonsensical "1 min" and "1 hour" starting factors. If you were to introduce "1 hour" as a starting factor in example 3 in Appendix A, you would be committing mathematical suicide as the problem would be rendered unsolvable once "hour" is cancelled out.

Here's an actual example from chapter 10: Calculation of IV Flow Rate When Total Infusion Time is Specified Order: 1000 mL of D5W (5% Dextrose in water) IV to infuse over a period of 5 hr Drop Factor: 10 gtt/mL Starting Factor Answer Unit 1 min gtt (drops)

Equivalents: 1000 mL = 5 hr, 10 gtt = 1 mL, 60 min = 1 hr Conversion Equation: 1 min x 60 min 1 hr x 1000 5 hr 1 mL mL x 10 gtt = 33.3 = 33 gtt

Flow Rate: 33 gtt/min

For review, let's go over this problem. 1. There are two errors relating to the starting factor. One is procedural--there is no logical way to pick a starting factor as the first step. The other is that "1 min" is a meaningless factor. I can meaningfully say that I know there are 10 drops per mL, but it means nothing to say that I know "1 min" in the context of this problem. 2. The answer unit is wrong. I want to know a rate of flow in drops per some unit of time. Just "gtt" doesn't cut it. 3. Factors are expressed as equalities. It should read "something per something" and not "something equals something" which leads to absurd statements like "25 mg = 1 kg" 4. By introducing a spurious starting factor the setup is in error, as is the resultant answer. The number is correct, but the answer unit is not. 5. The final statement, that the flow rate is 33 gtt/min, is the only part of the example that is correct, but it is logically disconnected from everything that precedes it. So, let's see, the text manages to state an incorrect answer unit, then introduces a spurious starting factor, which makes the setup wrong, which yields 33 gtt for an answer, which is also wrong. But through some sort of mental slight-of-mind, they finally come up with the correct answer, which they simply declare to be 33 gtt/min. Is there a better way to do this problem? First ask, what do I want to know? The flow rate in gtt/min, which is my answer unit, not just gtt (drops). What do I know? I'm given that there are

10 gtt/mL and that the infusion rate is 1000 mL/5 hr. Since I want gtt on top and 10 gtt/mL has gtt in the right place, 10 gtt/mL makes a perfectly good starting factor--I just need to get from mL to min. My set up then: 10 gtt 1 mL 5 hr x 1000 60 min mL min x 1 hr = 33 gtt

Just omitting the "1 min" from the textbook's setup would also work. As to what the authors might be thinking, the only clue to their reasoning was given in the following paragraph that preceded this example: "In calculating the flow rate for drops per minute, one minute becomes the labeled value that must be converted to an equivalent value: number of drops. One minute, therefore, is the starting factor and drops is the answer unit and these, as in all dimensional analysis conversions, form an equivalent relationship."

On page 9 is the following table: Table 1-2 Conversion Equation

This table reveals how the authors think about dimensional analysis. They see the starting factor as something given; there can be only one starting factor; it has only one unit associated with it, and it forms a special "equivalent relationship" with the answer unit, which, being equivalent, must also have only a single unit associated with it. In between are conversion factors that are fundamentally different from the starting factor. All of these assumptions are incorrect as generalizations about dimensional analysis. The only equivalent relationship is between what is on the left side of the equal sign and what is on the right side. One could speak of an equivalent relationship between the "numerator" and "denominator" of a conversion factor (2.2 lb/1 kg means 2.2 lb = 1 kg), but otherwise there is no necessary "equivalent relationship" implied. There is a particular type of DA problem, the simple conversion problem, that does involve going from one unit of measure to another equivalent measure (such as converting from feet to

meters). In this subtype of problem you have only one logical starting factor, which can be said to be equivalent to your answer (10 inches x 2.54 cm/1 inch = 25.4 cm), but such problems should not be taken as a model for all DA problems, which appears to be what has happened. By the Commutative Law of Multiplication, it doesn't matter what order the factors on the left side are multiplied in. Therefore any factor could be first, and thus be the starting factor, although usually only one or two factors qualify to be thought of as logical starting factors. Both starting factors and answer units are often in the form of something per something. You could start with miles/hour and end up with seconds in your answer, for example, without any equivalence between starting factor and answer unit. It appears that such fundamental misunderstandings underlie the errors in the textbook. Problems that do not conform to their notions are tortured into compliance by introducing spurious starting factors and using obviously incorrect answer units. I don't think it is going too far to suggest that the poor technique exhibited by the textbook makes it difficult for students to master med-math. Indeed, those who do must do so in spite of the textbook and not because of it. Go to top

**Recommended Corrections to Clinical Calculations: A unified approach (4th ed.)
**

Chapter 1 can be a useful supplement for students to read, but a more complete presentation of dimensional analysis should be given without closely following the material in this chapter. Page 1: A Google search shows that only this textbook and a few nursing sites associate "label factor" with dimensional analysis (DA). Likewise "unit conversion" is not a synonym for DA. The only synonym commonly used is "factor-label method." While this point is nit-picky, I would expect the authors to use the same terminology as everyone else by the 4th edition. Page 2: At the bottom, "Step I: Determining the Starting Factor and Answer Unit," should read, "Step I: Determining the Answer Unit." Determining the starting factor should come after Step II, since the starting factor is not always given, there can be more than one possible starting factor, and the best starting factor to use may be one of the factors determined in Step II. Picking a starting factor from what you are given or know is the first step of Step III--setting up/solving the conversion equation. Page 4: In the box is the statement: "When the conversion equation is solved, it will be seen that the starting factor and the labeled answer have formed an equivalent relationship." The belief that this is true leads to serious error and confusion in Chapter 10. If true, the collorilary would be that if the starting factor has one unit of measure associated with it, then the answer unit can have only one unit of measure associated with it and vice versa. Page 7: Emphasize that several of the equivalents in the table are fairly rough approximations. Give the actual equivalents--some students will want to know. Also, if the value of an equivalent can be 5% off, then, to be consistent, any test answer that is within +5% of the correct value

should be counted correct. In some (unlikely) cases answers could be as much as 10% off when several approximate equivalents are used to compound the error. Page 49: In the example at the bottom of the page you are given 25 mg/kg/24-hr (or day). The third unit given should not be dropped. There is a way to deal with problems of this type (25 mg/kg/day = 25 mg/kg-day) that can be consistently applied to all problems of this type. Triple unit factors are common and the difficulty they pose should be dealt with head on. All the various ad hoc attempts to get around these problems result in endless trouble in the long run. In this example the answer unit is given as "mL," whereas the correct answer unit is "mL/day." The problem should be setup as:

Whatever initial difficulty this technique may present for students not already familiar with it, it is still the technique of choice and will save a lot of grief later on. Some of the techniques contrived to deal with these problems work on some problems, but not others. The technique used above has the virtue of working with all problems involving triple unit factors. Page 50: In the two examples on this page the Answer Unit is incorrectly given as "cap" whereas "cap/dose" is what is really desired. In the first example, you are given 50 mg/kg/day and 4 doses/day, but not knowing what to do with "mg/kg/day" the problem is broken into two problems. The "day" is initially ignored, then brought back in the second part of the problem, thus paving the way for confusion and error. The logically consistent one-step setup would be:

For the second example the setup should be:

In the box at the bottom on the page are several warnings ("critically important," "easy to forget") that do not apply when the problems are done in a single step. Page 105: Avoid the two-step technique, and ignore the two examples at the bottom of the page. Work out as above. Page 159: Cross out the second paragraph: "In calculating the flow rate for drops per minute, one minute becomes the labeled value that must be converted to an equivalent value: number of

drops. One minute, therefore, is the starting factor and drops is the answer unit and these, as in all dimensional analysis conversions, form an equivalent relationship." Page 160: Ignore examples. Omit the spurious "1 min" Starting Factors. Note that Answer Units are also wrong (should be "gtt/min," not just "gtt"). All that needs to be done is to cross out the "1 min" at the beginning of each example and add "/min" to "gtt" (to get the correct answer unit). Pages 164, 165, and 166: Ignore these examples as above. Pages 177, 178: Again, ignore the spurious Starting Factors and use the correct Answer Units for the last two examples on page 177, and examples 2 and 3 on page 178. Pages 184, 185: Ignore examples. Another ad hoc variation in technique is introduced without comment in step 1 of the first example. Students will get into trouble if they try to extend this example to other problems. Also, what if the desired answer units were "mcg/hr?" Would students have trouble canceling out "min" with "min" apparently on top? Putting "mcg/min" on top invites confusion. A better setup for step 1 would be:

For step 2:

For steps 3 and 4, just omit the "1 min." and "1 gtt" Page 189, 190: Cross out the meaningless Starting Factors in examples 1, 3, 4, 5, and 6. In example 2, change "mcg/min" over "kg" to "mcg" over "kg x min." Page 196: In Example a., the setup is in error due to a failure to fully label units. The 10 mL is "10 mL water." You have to ask, "10 mL of what?" Your answer unit is "mL Chloromycetin sol" and not just "mL." You can't use "mL water" and end up with "mL Chlor. sol." When you add 10 mL water to reconstitute you will end up with somewhat more than 10 mL Chlor. solution. Since you want "mL Chlor. sol" in your answer, pick a factor that has "mL Chlor. sol" in it and in the right place. You are given "100 mg/mL" which should be more completely written as "100 mg Chlor./mL Chlor. sol" and "10 mL/g" should be "10 mL water/1 g Chlor." which is quite an unnecessary bit of information for solving this problem, though the text incorrectly uses it (and by luck gets away with it). The correct setup should be:

Page 205: Omit spurious Starting Factors from example.

Page 220, 221: The first example asks, "How many mL should the child receive per dose?" The answer unit, therefore, should be "mL/dose" and not "mL." You are given 15 mcg/kg/dose, so solve as shown above for examples on pages 49 and 50--likewise with the second example on page 221. Page 225: Again, example gives 50,000 U/kg/day and 4 doses/day, so a one-step setup would be:

That's about it. The other 96% of the text is okay. Go to top

**Textbook Guide to Dimensional Analysis
**

(as compiled from various pages throughout the textbook)

Determine the starting factor* and answer unit. Initially, it is essential to determine exactly what information is sought: the known quantity called the starting factor, and the desired unit to which the starting factor will be converted, the answer unit. When the conversion equation is solved, it will be seen that the starting factor and the labeled answer have formed an equivalent relationship. In calculating the flow rate for drops per minute (or mL per hour) one minute (or one hour) becomes the labeled value that must be converted to an equivalent value: number of drops (or mL). One minute, therefore, is the starting factor and drops is the answer unit and these, as in all dimensional analysis conversions, form an equivalent relationship. Formulate a conversion equation consisting of a sequence of labeled factors, in which successive units can be cancelled until the desired answer unit is reached. If a given is in the form mg/kg/day, ignore the third unit, do the conversion, then remember to factor the omitted unit back in. If in the form mcg/kg/min, change to mcg/min over kg if mcg/min is the answer unit. If a percentage is given, e.g. 25%, rewrite as 25/100 with appropriate labels. Determine conversion factors that may be needed. You will need enough to form a "bridge" to your answer unit(s). Use only conversion factors that have a 1:1 relationship

It is desirable that conversion factors be arranged in a sequence so that identical units are placed diagonally. In setting up the conversion factors, it is helpful to write the denominator first, as this contains the unit of the preceding numerator and facilitates cancellation of successive units. Solve the conversion equation by use of cancellation and simple arithmetic. Cancel units first Reduce numbers to lowest terms. Multiply/divide to solve the equation. Reduce answer to lowest terms, convert to decimal, and/or round off. Take a few seconds and ask yourself if the answer you came up with makes sense. If it doesn't, start over. * The text in red represents weak or erroneous technique. Errors of omission are not indicated.

Conclusions

This may be a case of a book being the worst textbook on dimensional analysis available--with the exception of all the others. I've heard that it is much better than its predecessor. Several medication math textbook titles are currently available, but not having reviewed them, I can't assume any do a better job, but I think other titles should be looked into. There are errors of omission where students are not given a complete enough understanding of dimensional analysis to do all problems that could crop up. There are errors of commission where students are taught flawed or even erroneous technique. Throughout the textbook, overly simplified examples are used that fail to show the range of problems that students may encounter. A wider range of problems, however, would have illustrated the shortcomings of the techniques as taught, and may have been omitted for that reason. Overall, however, I would say that this book is quite useable provided its shortcomings and flaws are amended. A better rounded, more robust presentation of dimensional analysis is definitely needed. Students should not only do well solving test problems, but come away feeling confident in their ability to handle any problems that may come their way in the future.