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­Acknowledgments
Our special thanks to the nursing and mathematics faculty B. Braun Medical Inc.
and the students at LaGuardia Community College and
© Copyright Eli Lily & Company. All rights reserved. Used
Kingsborough Community College. Also, a special thank
with permission.
you to our portfolio manager, Lisa Rahn, and content pro-
ducer, Michael Giacobbe, and to the marketing teams at Eisai Inc.
Pearson.
Endo Pharmaceuticals Inc.
Thank you also to the following manufacturers for supply-
Meda Pharmaceuticals
ing labels and art for this resource:
Courtesy of Novartis AG
Courtesy of Abbott Laboratories
Courtesy of Pfizer, Inc.
Courtesy of AbbVie
Teva North America
Actavis Pharma, Inc.

Reviewers
Paul Ache, III Carol A Penrosa MS, RN
Kutztown University of PA Instructor
Associate Degree Nursing
Michele Bach, MS, MS Southeast Community College
Professor Lincoln, NE
Kansas City Kansas Community College
Kansas City, Kansas Sonia Rudolph, MSN, APRN, FNP-BC
Jefferson Community & Technical College
Eileen Costello
Jason Shea
Dean, School of Health Professions, P
­ ublic Service ­Programs
Director of Mathematics
and Social Services
Goodwin College
Mount Wachusett Community College
Gladdi Tomlinson, RN, MSN
Jennifer Ellis, DNP, CNE Professor of Nursing
University of Cincinnati, Blue Ash College Harrisburg Area Community College

Dr. James E. Hodge, EdD. Linda Walter

University of Charleston, WV Northwestern Michigan College

Technical Reviewers
Katherine Poser, RN BScN MNEd Jeffrey N. McCulloch
Professor of Nursing Consultant
St Lawrence College School of Baccalaureate Nursing Retired Mathematics Instructor
Kingston, ON Wilmington, NC

vii
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 Learn to Calculate Dosages Safely
and Accurately!
The Ease of Learning Dosage Calculations
Dosage Calculations provides the ease of learning the 310
dimensional
Chapter 10 analysis, ratio & proportion, and formula methods
of calculation with a building-block approach of the basics.
(c) Because you want Drops per minute, Divide the
given flow rate by 6
Review of Arithmetic for Dosage Calculations 3 233.3
≈ 38.9
6
The Diagnostic Test of Arithmetic helps stu-
(c) Since the facility has a policy that flow rate adjustments must not exceed 25% of the original rate, you must now
Name: ________________________________________ Date: _______________________
calculate 25% of the original rate;dents
that is, 25%rediscover
of 21 gtt/min. their understanding of basic
25, of 21 gtt/min = (.25 * 21) gtt/min
math concepts and guides them in identifying
= 5.25 gtt/min
Diagnostic Test of Arithmetic So, the flow rate may not be changed areas by moreforthanreview.
about 5 gtt/min. Therefore, the initial flow rate of 21 gtt/min can be
changed to no less than 16 (21 minus 5) gtt/min and no more than 26 (21 plus 5) gtt/min.
The following Diagnostic Test illustrates all the arithmetic skills needed to do the compu-
Since 39 gtt/min is outside the acceptable range of roughly 16–26 gtt/min, this change is not within the guidelines and
tations in this textbook. Take the test and compare your answers with the answers the found
adjustment may not be made. You must contact the prescriber.
in Appendix A. If you discover areas of weakness, carefully review the relevant review
materials in this chapter so that you will be mathematically prepared for the rest of the Fluid Balance: Intake/Output
textbook. To work well, the various body systems need a stable environment in which their tissues
and cells can function properly. For example, the body requires somewhat constant levels of
1. Write 0.375 as a fraction in lowest terms. _________ temperature, salts, glucose, and, in particular, adequate hydration to maintain homeostasis.
28,500 Part of hydration management involves the monitoring of a client’s fluid intake and
2. Write 100,000 as a decimal number. _________ output. This is especially important with pediatric, geriatric, renal, cardiac, and critical
care clients.
3. Round off 6.492 to the nearest tenth. _________ Fluid intake is the amount of fluid that enters the body (oral and parenteral fluids),
whereas fluid output is the amount of fluid that leaves the body (urine, sweat, liquid
4. Write 56 as a decimal number rounded off to the nearest hundredth.162 Chapter 6
_________
stool, emesis, and drainage).
Fluid replacement is sometimes necessary to avoid dehydration. If (as in Example 10.15)
5. Simplify 0.63
0.2 to a decimal number rounded off to the nearest tenth. _________
FORMULA METHOD a physician provides an order withANALYSIS
DIMENSIONAL a specific ratio comparing the necessary replacement
6. 0.038 * 100 = _________ fluid with the client’s fluid output and if the client’s fluid output is known, then dimensional
D (desired dose) = 0.4 g analysis could be used
Given quantity: the volume0.4
to determine of greplacement fluid to give the client.
7. 4.26 * 0.015 = _________ H (dose on hand) = 100 mg
Strength: 1 tab = 100 mg
Q (dosage unit) = 1 tab
8. 55 , 0.11 = _________ X (unknown) Example = ? tab 10.16
Quantity you want to find: ? tab
You need to Order:
first convert 0.4 g 100
For every to anmL
equivalent
of urineamount In this
output, replace problem
with 40 mLyou want tovia
of water convert 0.4 gram
PEG tube q4h.toThe client’s urine
1 20
9. 90 * 300 * 3 = _________ of milligrams.output is 300 mL. What is the replacement volume? milligrams and then convert milligrams to tablets.
kilogram gram milligram microgram
10. Write 5 34 , 23 as a fraction and as a decimal number. _________ 0.4 g ¡ ? mg ¡ ? tab
kgDIMENSIONAL
g mg
ANALYSIS mcg RATIO & PROPORTION
You can do this on one line as follows
7 3
11. Write 100 , 100 as a mixed number. _________ Think of the problem as: Think of the problem
? mg ? tabas:
4 0.4 g * * = ? tab
Output: 300 mL (out) [single unit of measurement] 100? mL
g (output)
? mg = 40 mL (input) [order]
5 Move the decimal point 3 places to the right
12. Write 20 as a simple fraction in lowest terms. _________ Replacement: 100 mL (out)/ 300 mL (output) = x mL (input) 1,000 [client]
mg
0.4 g = 0.400 g = 0. 4 040 0 gmL 0400. mg
= (in) = 400 mg
[equivalence] Because 1,000 mg = 1 g, the first unit fraction is
The proportion could be set up as 1g
Input: ? mL (in) [single unit of measurement]
Because 100 mg = 1 tab, the second unit fraction is
13. Write 45% as a fraction in lowest terms. _________ Fill in the formula
D
In this example,
* Q = you
X want to change the single unit of 1 tab
Out
=
Out′
H In In′
measurement [300 mL(out)] to another single unit of 100 mg
14. Write 2 12% as a decimal number. _________ 400 mg
measurement [mL(in)].
Substituting, you get
10
* 1 tab = ? tab 1,000 mg 100 mL
1 tab 300 mL
100 mg 300 mL(out) = ? mL(in) 0.4 g * * ==4 tab
15. Write 2 47 as an improper fraction. _________ 400 mg
1g 40 mL
100
1
mg x mL
Cancel The flow rate provides
* 1 tabthe=equivalence
? tab [100 mL(out)/40
100 mg 12,000 = 100x
16. 30% of 40 = _________ mL(in)] for the unit fraction.
Multiply 4 * 1 tab = 4 tab 120 = x
40 mL(in)
17. 4.1 + 0.5 + 3 = _________ 300 mL(out) * = 120 mL(in) So, the replacement volume is 120 mL.
So, 4 tablets will contain 0.4 g of the100 mL(out)
drug.
3 ?
18. = _________ So, the replacement volume is 120 mL.
4 8
NOTE
19. Which is larger, 0.4 or 0.21? _________
Learn by Example. Each chapter Although Example 6.12 would be simpler using milligrams, we do the calculation using
micrograms to practice complex problems. For safety purposes, drug manufacturers
20. Express the ratio 15 to 20 as a fraction in lowest terms. _________ often place both microgram and milligram concentrations on drug labels.
­unfolds basic concepts and skills M10B_GIAN4679_02_SE_C10.indd 310 5/27/17 8:44 AM

through completely worked-out Example 6.12

questions with solutions. The order is Tikosyn (dofetilide) 0.5 mg PO b.i.d. Read the label shown in Figure 6.14. Calculate how many
capsules of this antiarrythmic drug should be given to the client. Although there are two strengths on the
label (mcg and mg), calculate the problem using microgram strength.

Figure 6.14 Drug label for Tikosyn.

(Reg. trademark of Pfizer Inc. Reproduced with permission.)

M01B_GIAN4679_02_SE_C01.indd 3 5/19/17 2:43 PM

ix
M06B_GIAN4679_02_SE_C06.indd 162 7/6/17 6:12 PM
 Safe and Accurate Dosage Calculation Converting from One System of Measurement to Another

3. Order: Ravicti (glycerol phenylbutyrate) 15 mL po in three equally divided dosages, each

139

rounded up to the nearest 0.5 mL. How many teaspoons will you administer?
4. How many milliliters are in an 8-ounce cup of coffee?
Safe and accurate dosage calculation comes from practice and critical thinking.
5. A client is told to drink 2,500 milliliters of fluid. How many quarts of fluid should
the client drink? Converting from One System of Measurement to Another 141

Try These for Practice, Exercises, and 15. Order: Nuplazid (pimavanserin) 34 mg PO daily. The strength of the drug is 17 mg
Exercises
per tablet. How many tablets of this selective serotonin inverse antagonist should be
Syringes 225
­Additional Exercises, found in every chapter,
given to the client?
Reinforce your understanding in class or at home.
16. An indwelling urinary catheter drains into a collection bag that contains 1,200 mL
1. 4 t ≈ mL
of urine.
19. Nafcillin sodium isHow many ounces
ordered IM forofan urine are inclient.
adult the collection bag?
The strength of the nafcillin
test your comprehension of material. sodium on 17. 8 oz ≈
2. Percocet mL is a combination drug with strength of 2.5 mg/325
hand is(oxycodone/acetaminophen)
250 mg/mL. Is the amount shown by the arrow on the syringe
3. mg
45 per
mLtablet.
≈ How many grams T of acetaminophen are contained in one tablet?
the correct dose to administer?
18. Harold is producing urine at the rate of 40 milliliter/hour, and Thomas is producing
4. 120 mL ≈ cup
urine at 1.5 quart/day. Which person is producing urine at the faster rate?
er 5 5. 150 lb ≈ kg (round off to tenth of a kg)
19. A bottle of acetaminophen and codeine phosphate has a volume of 473 mL. The adult
6. dose
Order: albuterol
of this drug issulfate 2 mg po
1 tablespoon. t.i.d.
How Read
many fullthe label
adult in Figure
doses 5.3 and
are contained in determine
the the
number of teaspoons of syrup that are contained in one dose.
bottle?

Practice Sets 20. A morbidly obese client weighs 420 pounds. What is the client’s weight in
kilograms?

The answers to Try These for Practice, Exercises, and Cumulative Review Exercises are found Figure 5.3 Drug
Additional Exercises
label for Albuterol Sulfate Syrup.
in Appendix A. Ask your instructor for the answers to the Additional Exercises. Now, test yourself!
1. 4.7 mg = mcg
20. Indicate, by
2. placing
400 mL = an arrow onLthe syringe, the dose of nalbuphine HCl to be
Try These for Practice administered
3. 60IM ≈ severe pain.
mL for t The strength available is 10 mg/mL, and the adult
172 Chapter 6 4. 4 T ≈ kg. mL
Test your comprehension after reading the chapter. client weighs 105
5. 50 lb ≈ kg (round off to the nearest tenth)
1. To do the exercises at the end of this chapter, you need to memorize all the equiva- 6. 50 kg ≈ lb
Summary
lents presented so far. To test yourself, fill in the missing numbers in the following 7. 3.5 pt ≈ oz

chart. 8. 4 T = oz
In this chapter, you learned the computations necessary to • D and H must always have the same units of measurement, 9. 7.5 cm ≈ in
calculate dosages of oral medications in liquid and solid and Q and X must have the same units of measurement. 10. How many tablespoons are contained in the Lexapro container whose label is shown
in Figure 5.6?
Metric System
form. You also learned about the equipment used to accu-
rately measure liquid medication.
• If the desired dose ordered is in a different unit of
measurement than the dose on hand, convert them to
(a) 1 L = mL
• It is crucial to ensure that every medication adminis-
the same unit of measurement before using the formula. Figure 5.6 Drug label for Lexapro.

(b) 1iskg
tered = the recommendedgsafe dosage range.
within Calculating doses based on body weight
(c) 1 g doses
Calculating = mg in solid and
for oral medications • Dosages based on body weight are generally measured
liquid
(d) form
1 mg = mcg in milligrams per kilogram (mg/kg).
Cumulative ReviewdrugExercises Cumulative Review Exercises
• The
(e) label
1 cmstates
= the strength of themm (e.g., 10 mg/tab, begin in
• Start calculations with the weight of the client.
15 mg/mL). Review your mastery of previous chapters.
• Multiply the size of the client (kg) by the order to obtain
­C hapteroral4 medications
• Sometimes and review mastery
are ordered in liquid formof earlier
the dose. chapters. 7. The diameter of a wound is 50 mm. What is the diameter of the wound measured in
1. Prescriber’s order:
LOT NO. 189462

inches? Administer Humulin R (regular insulin [rDNA origin]) subcutane-

for special populations such as pediatrics, geriatrics, and • Size of the Client * Order = Dose EXP. DATE Aug. 2016
ously as per8.the following blood-glucose results:
24 t = ? T
Household System
clients with neurological conditions. • Medications may be prescribed by body weight in spe-
9.
11. 120
A mLis≈5 feet
client ? oz9 inches tall. Find the height of the client in centimeters.
cial populations such as pediatrics and geriatrics.
Case Studies. Clinical case scenarios provide
• Some medication cups cannot accurately measure vol-
(f) 1 qt =
umes less than 5 mL.
pt 12. Find
10. Readthethe
For glucose less than 160 mg/dL
weight ingrams
labelin Figureof a5.4
7-pound infant (round
and determine howoff many
—no insulin
to the nearest gram).
teaspoons of dextromethor-
Calculating doses based on body surface area glucose 160
13. mg/dL–220
phan are
Harold mg/dL
in the
weighs pounds now. —give
250container. If Harold2goes
unitson a diet and loses 30 pounds, then
opportunities for critical thinking •asBody
(g) 1 pt
• Special =
calibrated cups
droppers or oral you apply
syringes that are sup-
surface area (BSA) is measured in square meters (m ).
how many kilograms
glucose 221 mg/dL–280 mg/dL will he weigh?
2 —give 4 units
plied with some liquid oral medications may be used to
(h) 1 cup = oz 14. Use Figure 5.7 to determine the total number of grams of pseudoephedrine that are
concepts and techniques presented• in
administer only those medications.
oz = such as electrolytes,
(i) 1 drugs,
Startthe text.with the BSA of the client.
calculations
T are measured in
glucose 281 mg/dL–340 mg/dL
in the entire container.
glucose 341 mg/dL–400 mg/dL
2
—give 6 units
—give 8 units
• Some • Multiply the size of the client (m ) by the order to obtain
milliequivalents
(j) 1 T = (mEq). t the dose. glucose greater than 400 mg/dL —notify MD stat
• Size of the Client * Order = Dose
Calculating
(k) 1 lb dosages
= using the formula
oz method • BSA is estimated by using a formula. How many units will you administer if the client’s glucose level at lunchtime is
M05_GIAN4679_02_SE_C05.indd 141 5/19/17 2:52 PM
D M05_GIAN4679_02_SE_C05.indd 139 5/19/17 2:52 PM
• The 1 ft = H * Q = X can be used
(l) formula in to calculate dosages. • BSA may be utilized to determine dosages for special(a) 140 mg/dL?
• Always include the units of measurement when setting client populations such as those receiving cancer ther-(b) 200 mg/dL?
up the formula. apy, burn therapy, and for clients requiring critical care. (c) 450 mg/dL?
2. If 40 mg of a drug is ordered po daily and the strength of the drug is 10 mg/mL, how
Mixed Systems
Case Study 6.1
(m) 1 in ≈ cm
many milliliters will you administer?
3. If 40 mg of a drug is ordered po b.i.d. and the strength of the drug is 10 mg/mL, how
Read
(n) 1the
kgcase
≈ study and answer the
lb questions. Answers can be found in Appendix A. many milliliters will you administer?

A 1 t ≈ female is admitted
(o)67-year-old mL to the ambulatory Make appointment for follow-up care 2 weeks after 4. If 40 mg of a drug is ordered po daily in two divided doses and the strength of the drug
•
surgery is 10 mg/mL, how many milliliters will you administer?
(p) 1 Tcenter
≈ for a repair of her mLfractured patella. An discharge
ORIF (open reduction external fixation) is planned. She ondansetron HCl 4 mg PO q6h prn nausea
• 5. If 40 mg of a drug is ordered po q12h and the strength of the drug is 10 mg/mL, how
oz ≈ of heart failure, hypertension,
(q) a1history
has mL hyperlipi- •
oxycodone/acetaminophen (Percocet) 2.5/325 many milliliters will you administer?
demia,
(r) 1 osteoarthritis,
cup ≈ and Parkinson’s
mLdementia. She has mg PO one or two tab q6h for pain. Take Percocet
a past surgical history of four caesarean sections and a before becoming too uncomfortable.
(s) 1 pt ≈ mL
cholecystectomy. She is 5 feet 7 inches tall and weighs •
Resume pre-admission medications
1 qt ≈ She denies any allergies
(t) pounds.
150 mL to food or drugs, – diltiazem HCl (Cardizem LA) extended-release
does not smoke, and drinks wine socially. Her vital signs 180 mg PO daily
(u) 1 oz = T = t ≈ mL
on admission were: T 98.8° F; B/P 148/94; P 104 R 22. She – rivastigmine tartrate (Exelon) 3 mg PO B.I.D.
(v) 1 qta =
received pt =
regional block anesthesia, cups =
progressed oz ≈
well in mLmeals
with M07_GIAN4679_02_SE_C07.indd 225 5/19/17 3:1

the recovery room, and is preparing for discharge home. – valsartan (Diovan) 80 mg PO daily
2. Harold is 5 feet 3 inches tall. What is his height rounded off to the nearest whole
– atorvastatin (Lipitor) 20 mg PO daily
centimeter?
Discharge orders – docusate sodium (Colace) 100 mg PO T.I.D.

• Knee immobilizer, elevate leg, move toes as much
as possible
• Ice to knee 20 minutes every hour
• Crutches, non-weight-bearing
• Observe for increased swelling or sudden severe pain
1. Select the appropriate label and calculate how many
tablets of diltiazem HCl the client will take each day.
2. Select the appropriate rivastigmine tartrate label and
calculate how many capsules the client will take in
24 hours.

dd 138 5/19/17 2:52 PM

M06B_GIAN4679_02_SE_C06.indd 172 5/19/17 3:05 PM

x
 in the hub; and the bevel, the slanted p
the needle. The length of the needle is th
commonly used in medication admini
When
Notes andsmall
Alertsvolumes
highlight concepts the needle
of 1 milliliter forrefers
or less
and principles to the thickness
are required,
safe of th
a low-vol
ALERT medication
vides calculation
the greatest gauge,
and administration.
accuracy. The 1 mL the thinner
syringe, the needle).
also called The par
a tuberculin
The calibrations on the 1 mL in Figure 7.11, is calibrated in hundredths of a milliliter. Because there
syringe are very small and close the syringe, each line represents 0.01 mL. The 0.5 mL syringe, shown in
together. Use caution when 50 lines, and each line also represents 0.01 mL. of 0.5 mL
drawing up medication in this Figure 7.2 For doses
Parts of a syringe andor
ne
syringe. should be used. These syringes are used for intradermal injection of ve
of substances Parts
NOTE in tests for tuberculosis and allergies, of a 10
as well as mL Luer-L
for intram
of smallThe
quantities of medication.
two rings on the stopper are
called “top” ring and “bottom”
ring because when the syringe
is held with the needle facing
Figureupward,
7.11theA“top”
partially filled
ring is above 1 mL safety tuberculin syringe.
the “bottom” ring. Syringes 191

ALERT
0.52 mL Barrel Ca
The amount of fluid to be put in the syringe, the client’s size, the type of tissue being
injected, and the viscosity of the medication are factors that determine the size of
the needle to be used. The inside of the barrel, the plunger, the tip of the syringe,
and the needle should never come in contact with anything unsterile.

Commonly Used Sizes

of Hypodermic Syringes
Realistic Illustrations. Real drug labels
The two major types of syringes are hypodermic and oral. In 1853, doctors Charles Pravaz
and Alexander Woodand were
realistic
the firstsyringes
to develop aaid in identifying
syringe with a needle thatandwas fine Plunger
enough to piercepracticing
the skin. This iswith as a hypodermic
knownwhat syringe.
you will encounterUse of oral in
syringes
(without needles) are discussed in Chapter 12.
Hypodermic actual clinical
syringes are settings.
calibrated (marked) in cubic centimeters (cc), milliliters
(mL), or units. Practitioners often refer to syringes by the volume they contain—for
example, a 3-cc syringe. Although some syringes are still labeled in cubic centimeters,
manufacturers are now phasing in syringes labeled in milliliters. In this text, we gener-
The top ring of the plunger in Figure 7.11 is at the second line after 0
ally show mL instead of cc on the syringes.
The smaller-capacity syringes (0.5, 1, and 3 mL) are used most often for intrader-
the amount in the syringe is 0.52 mL.
mal, subcutaneous, or intramuscular injections of medication. The larger sizes (5, 12, and
35 mL) are commonly used to draw blood or prepare medications for intravenous admin-
istration. A representative sample of commonly used syringes is shown in Figure 7.3. Shaft
Figure 7.3 A sample of commonly used hypodermic syringes (35 mL, 12 mL, 5 mL, 3 mL,
Figure1 mL,
7.12 A partially filled 0.5 mL safety syringe.
and 0.5 mL).
Hub

Needle

The top ring of the plunger in Figure 7.12 is at the first line before
M07_GIAN4679_02_SE_C07.indd 190
90 min
Therefore, the syringe contains 0.29 mL.

120 mL

The space between two numbers on a syringe is broken up into either 2, 5, or 10 seg-
ments; this divides the space into halves, fifths, or tenths, respectively. For example, if
the space between 2 mL and 3 mL on a syringe is divided into two equal segments, then
? mL/h
M07_GIAN4679_02_SE_C07.indd 194 Schematic Diagrams To help students visual-
ize some of the more difficult mathematical
Client
conceptsM07_GIAN4679_02_SE_C07.indd
involved in solutions 191 and IVs. 5/19/1

xi
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A01_THOM6233_05_SE_WALK.indd 9 1/13/17 6:50 PM

Contents
Unit 1 Basic Calculation Skills and Medication Orders 42
Types of Medication Orders 42
Introduction to Medication Components of a Medication Order 44
Administration1 Medication Administration Records 47

1 Review of Arithmetic for

Technology in the Medication Administration
Process: Preventing Medication Errors 52
Dosage Calculations 2 Drug Labels 54
Diagnostic Test of Arithmetic 3 Combination Drugs 58
Decimal Numbers and Fractions 4 Controlled Substances 59
Changing Decimal Numbers Drug Information 60
to Fractional Form 4 Prescription Drug Package Inserts 60
Mixed Numbers and Improper Fractions 4 Over-the-Counter (OTC) Labels 61
Calculator 5 Summary 64
Ratios 6 Practice Sets 64
Changing Fractions to Decimal Numbers 7
Rounding Decimal Numbers 9 3 Dimensional Analysis
Rounding Off 9 and Ratio & Proportion 77
Rounding Down and Rounding Up 9
Dimensional Analysis 77
Adding and Subtracting Decimal Numbers 10 Introduction to Dimensional Analysis 77
Multiplying Decimal Numbers 11 The Mathematical Foundation for
Dividing Decimal Numbers 12 Dimensional Analysis 77
Estimating Answers 13 Changing a Single Unit of Measurement to Another
Multiplying Fractions 14 Single Unit of Measurement 79
Dividing Fractions 15 Simple (One-Step) Problems with Single
Units of Measurement Using Dimensional Analysis 79
Complex Fractions 17
Ratio & Proportion 80
Addition and Subtraction of Fractions 19
Ratios 80
Same Denominators 19
Rates 83
Different Denominators 20
Proportions 85
Percentages 21
The Mathematics Needed to Solve Proportions 86
Percent of Change 23
Using Parentheses to Indicate Multiplication 86
Summary 23
Multiplying by 1 86
Practice Sets 24
Dividing by 1 86
Shorthand for Multiplication 86
Commutative Property 87
2 Safe and Accurate Cancelling 87
Medication Administration 28 Solving Simple Equations 87
The Medication Administration Process 28 Solving Proportions 88
Preventing Medication Errors 29 Simple (One-Step) Problems with Single
Units of Measurement Using Ratio & Proportion 92
Six Rights of Medication Administration 30
Simple (One-Step) Problems with Single
The Right Drug 30 Units of Measurement using both Dimensional
The Right Dose 32 Analysis and Ratio & Proportion 94
The Right Route and Form 34 Complex (Multi-Step) Problems with Single
The Right Time 36 Units of Measurement 97
The Right Client 37 Changing One Rate to Another Rate 100
The Right Documentation 38 Simple (One-Step) Problems with Rates 100
Drug Prescriptions 41 Complex (Multi-Step) Problems with Rates 102
xiii
xiv Contents

Summary 106
7 Syringes 189
Practice Sets 107
Parts of a Syringe 190

Unit 2 Systems of Measurement 109 Needles 190

Commonly Used Sizes of Hypodermic Syringes 191

4 The Household and Metric Systems 110 Insulin

Insulin Syringes
195
196
The Household System 111 Types of Insulin 197
Liquid Volume in the Household System 111 Insulin Concentrations 198
Weight in the Household System 113 Types of Insulin 198
Length in the Household System 114 Insulin Pens 201
Decimal-Based Systems 115 Insulin Pumps 202
The Metric System 115 Measuring Two Types of Insulin in One Syringe 204
Liquid Volume in the Metric System 116 Premixed Insulin 206
Weight in the Metric System 118 Insulin Coverage/Sliding-Scale Calculations 207
Length in the Metric System 121 Prefilled Syringes 207
Summary 122 Safety Syringes 209
Practice Sets 122 Needleless Syringes 209

5
Dosing Errors with Syringes 210
Converting from One System Summary 211
of Measurement to Another 129 Case Study 7.1 211
Equivalents of Common Units of Measurement 129 Practice Sets 215
Metric-Household Conversions 131
Volume Conversions 131 8 Solutions 227
Weight Conversions 133
Introduction 227
Length Conversions 135
Strengths of Solutions Using Explicit
Summary 137
Units of Measurement 228
Practice Sets 138
Strengths of Solutions as Ratios, Fractions,
and Percents 228
Unit 3 Oral and Parenteral Liquid Solutes 230
Medications145 Dry Solutes 231
Determining the Amount of Solute in a Given
6 Oral Medications 146 Amount of Solution 233
Determining the Amount of Solution That
Simple (One-Step) Problems 146
Contains a Given Amount of Solute 238
Medication in Solid Form 146
Irrigating Solutions, Soaks, and Oral Feedings 240
Formula Method 147
Summary 243
Using the Formula Method 148
Case Study 8.1 243
Using Ratio & Proportion 149
Practice Sets 246
Using Dimensional Analysis 149
Medication in Liquid Form 153
Medications Measured in Milliequivalents 157 9 Parenteral Medications 251
Complex (Multistep) Problems 158 Parenteral Medications 251
Dosages Based on the Size of the Client 166 Parenteral Medications Supplied as Liquids 252
Dosages Based on Body Weight 166 Parenteral Medications Supplied in Powder
Dosages Based on Body Surface Area 169 Form: Reconstitution 258
BSA Formulas 169 How to Use a Two-Chambered Vial 265
Summary 172 Heparin 267
Case Study 6.1 172 Summary 272
Practice Reading Labels 174 Case Study 9.1 272
Practice Sets 180 Practice Sets 275
 Contents xv

Unit 4 Infusions and Adding Medication to an IVPB Bag 334

Titrated Medications 338
Pediatric Dosages 289
Summary 341
10 Flow Rates and Durations of Case Study 11.1 341
Enteral and Intravenous Infusions 290 Practice Sets 342

Introduction to Enteral and Intravenous Solutions

Enteral Feedings
290
290
12 Pediatric Dosages 350
Intravenous Infusions 291 Pediatric Drug Dosages 350
Intravenous Solutions 292 Oral Medications 351
Gravity Systems and Pumps 295 Parenteral Medications 351
Calculations for Infusions 297 Dosages Based on Body Size 352
Finding the Flow Rate on a Pump 297 Dosages Based on Body Weight 352
Finding the Volume Infused Using a Pump 299 Dosages Based on BSA 355
Finding the Duration of an Infusion Using a Pump 300 Determining Safe Dosage Range 357
Flow Rate Conversion Number 301 Intravenous Medications 360
Finding the Flow Rate (Drip Rate) Using a Using a Volume-Control Chamber 360
Gravity System 302
Calculating Daily Fluid Maintenance 363
Finding the Volume Infused Using a Gravity System 304
Summary 365
Finding the Duration of an IV Using a Gravity System 305
Case Study 12.1 365
Adjusting the Flow Rate of an IV 308
Fluid Balance: Intake/Output 310 Practice Sets 366
Summary 311
Comprehensive Self-Tests 374
Case Study 10.1 311
Practice Sets 312
Appendices 385
11 Flow Rates and Dosage Rates APPENDIX A Answer Section 386
for Intravenous Medications 317 APPENDIX B FDA and ISMP Lists of Look-Alike
Drug Names with Recommended
Intravenous Administration of Medications 318
Tall Man Letters 402
Intravenous Piggyback Infusions 318
APPENDIX C Commonly Used Abbreviations 408
Finding the Dosage Rate 319
APPENDIX D Units of Measurement in Metric
Converting IV Dosage Rates to Flow Rates 320 and Household Systems 410
Converting IV Flow Rates to Dosage Rates 324 APPENDIX E Celsius and Fahrenheit Temperature
Safe Dose Range 324 ­Conversions 411
Determining Amount Infused and Duration APPENDIX F Diluting Stock Solutions 413
of an Infusion 326
APPENDIX G Apothecary System 416
IV Push 328
Compound Rates 330 Index 421
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A01_THOM6233_05_SE_WALK.indd 9 1/13/17 6:50 PM

Unit 1
Basic Calculation
Skills and I­ ntroduction
to Medication
Administration
CHAPTER 1  eview of Arithmetic for Dosage
R
­Calculations
CHAPTER 2  afe and Accurate Medication
S
­Administration
CHAPTER 3  imensional Analysis and
D
Ratio & ­Proportion
Chapter 1
Review of Arithmetic
for Dosage Calculations
Learning Outcomes
After completing this chapter, you will be able to
1.1 Reduce and build fractions into equivalent forms.

1.2 Add, subtract, multiply, and divide fractions.

1.3 Simplify complex fractions.

1.4 Convert between decimal numbers and fractions.

1.5 Add, subtract, multiply, and divide decimal numbers.

1.6 Round decimal numbers to a desired number of decimal places.

1.7 Write percentages as decimal numbers and fractions.

1.8 Find the percent of a number and the percent of change.

1.9 Estimate answers.

1.10 Use a calculator to verify answers.

Medical dosage calculations can involve whole numbers, fractions, decimal numbers, and
percentages. Your results on the Diagnostic Test of Arithmetic, found on the next page, will
identify your areas of strength and weakness. You can use this chapter to improve your
math skills or simply to review the kinds of calculations you will encounter in this text.
 Review of Arithmetic for Dosage Calculations 3

Name: ________________________________________ Date: _______________________

Diagnostic Test of Arithmetic

The following Diagnostic Test illustrates all the arithmetic skills needed to do the compu-
tations in this textbook. Take the test and compare your answers with the answers found
in Appendix A. If you discover areas of weakness, carefully review the relevant review
materials in this chapter so that you will be mathematically prepared for the rest of the
textbook.

1. Write 0.375 as a fraction in lowest terms. _________

28,500
2. Write 100,000 as a decimal number. _________

3. Round off 6.492 to the nearest tenth. _________

4. Write 56 as a decimal number rounded off to the nearest hundredth. _________

5. Simplify 0.63
0.2 to a decimal number rounded off to the nearest tenth. _________

6. 0.038 * 100 = _________

7. 4.26 * 0.015 = _________

8. 55 , 0.11 = _________
1 20
9. 90 * 300 * 3 = _________

10. Write 5 34 , 23 as a fraction and as a decimal number. _________

7 3
11. Write 100 , 100 as a mixed number. _________
4
5
12. Write 20 as a simple fraction in lowest terms. _________

13. Write 45% as a fraction in lowest terms. _________

14. Write 2 12% as a decimal number. _________

15. Write 2 47 as an improper fraction. _________

16. 30% of 40 = _________

17. 4.1 + 0.5 + 3 = _________

3 ?
18. = _________
4 8

19. Which is larger, 0.4 or 0.21? _________

20. Express the ratio 15 to 20 as a fraction in lowest terms. _________

4 Chapter 1

Decimal Numbers and Fractions

Changing Decimal Numbers to Fractional Form
A decimal number represents a fraction with a denominator of 10; 100; 1,000; and so on.
Each decimal number has three parts: the whole-number part, the decimal point, and the
fraction part. Table 1.1 shows the names of the decimal positions (places values).

Table 1.1 Names of Decimal Positions.

Whole-Number Fraction
Part Part

0 0 0 0 . 0 0 0 0

thousands ten thousandths

hundreds thousandths
tens hundredths
ones tenths
decimal
point

Reading a decimal number will help you write it as a fraction.

Decimal Number ¡ Read ¡ Fraction

NOTE
4.1 ¡ four and one tenth ¡ 1
4
A decimal number that is less 10
than 1 is written with a ­leading
zero—for example, 0.3 and
0.3 ¡ three tenths ¡ 3
0.0025. 10
6.07 ¡ six and seven hundredths ¡ 7
6
100
0.231 ¡ two hundred thirty-one thousandths ¡ 231
1,000
0.0025 ¡ twenty-five ten thousandths ¡ 25
10,000

A number can be written in different forms. A decimal number less than 1, such as 0.9,
9
is read as nine tenths and also can be written as the proper fraction 10 . In a proper fraction,
the numerator (the number on the top) of the fraction is smaller than its denominator
(the number on the bottom).

Mixed Numbers and Improper Fractions

A decimal number greater than 1, such as 3.5, is read as three and five tenths and can also be
5
written as the mixed number 3 10 or reduced to lowest terms as 3 12. A mixed number com-
bines a whole number and a proper fraction. The mixed number 3 12 can be changed to an
improper fraction as follows:
1 3 * 2 + 1 7
3 = =
2 2 2
The numerator of an improper fraction is larger than or equal to its denominator.
Any number can be written as a fraction by writing it over 1. For example, 9 can be
written as the improper fraction 91.
 Review of Arithmetic for Dosage Calculations 5

Calculator
To help avoid medication errors, many healthcare agencies have policies requiring
that c­ alculations done by hand be verified with a calculator. “Drop-down” calcula-
tors are available on the computer screen to candidates who are taking the National
Council Licensure E ­ xamination for Registered Nurses (NCLEX-RN) or the National
Council Licensure Examination for Practical Nurses (NCLEX-PN). Therefore, it is
important to know how to use a calculator.
A basic four-function (addition, subtraction, multiplication, and division), handheld
calculator with a square-root key is sufficient to perform most medical dosage cal-
culations. See Figure 1.1.

Figure 1.1 Basic handheld calculator.

Square root

Multiplication
Division

Addition
Subtraction

Equals

Some students might prefer a calculator that also has a percent key , a fraction NOTE
key , and parentheses keys and . Some calculators use the
7
To change the improper fraction to a decimal number with a calculator:
2
key rather than the

First press 7 key.

Then press
Then press 2
Then press
The display shows 3.5

This keystroke sequence will be abbreviated as 7 2 3.5

If the calculator has a fraction key, the mixed-number form of 72 will be obtained by the
following keystroke sequence:

7 2 3 12

Throughout this chapter, keystroke sequences are shown for selected examples. The
­calculator icon, , indicates where this occurs.

NOTE

The keystroke sequences presented in this chapter apply to many calculators. But
not all calculators work the same way. If you have a problem, consult the user’s
manual for your calculator.
6 Chapter 1

Example 1.1
Write 2.25 as a mixed number and as an improper fraction.
25
The number 2.25 is read two and twenty-five hundredths and is written 2 100 . You can
simplify:
1
25 25 1 2 * 4 + 1 9
2 = 2 = 2 = =
100 100 4 4 4
4

So, 2.25 can be written as the mixed number 2 14 or as the improper fraction 94

Keystroke Sequence for Example 1.1:

To obtain the simplified mixed number, enter the following keystroke sequence.

2 25 100 214

Ratios
A ratio is a comparison of two numbers.
5
The ratio of 5 to 10 can also be written as 5:10 or in fractional form as 10 . This fraction
may be reduced by cancelling by a number that evenly divides both the numerator and the
denominator. Because 5 evenly divides both 5 and 10, divide as follows:

5 5 , 5 1
= =
10 10 , 5 2

5
The fraction 10 is reduced to lowest terms as 12.
So, the ratio of 5 to 10 can also be written as the ratio of 1 to 2 or 1:2

Keystroke Sequence for Example 1.2:

1
6 18 = 3

Example 1.2
Express 6:18 as an equivalent fraction and ratio in lowest terms.
6
The ratio 6:18, also written as 6 to 18, can be written in fractional form as 18 . This
fraction may be reduced by cancelling by a number that evenly divides both the
numerator and the denominator. Because 6 divides both 6 and 18, divide as follows:
6 6 , 6 1
= =
18 18 , 6 3
So, the ratio 6 to 18 equals the fraction 13 and the ratio 1:3

Keystroke Sequence for Example 1.3:

To check the answer, use

1
12 120 10
 Review of Arithmetic for Dosage Calculations 7

Example 1.3
Write the ratio 1:10 as an equivalent fraction with 120 in the denominator.
1
Because 1:10 as a fraction is 10 , you need to write this fraction with the larger
denominator of 120. Such processes are called building fractions.
1 ?
=
10 120
1
10may be built up by multiplying the numerator and denominator of the fraction by the
same number (12 in this case) as follows:
1 1 * 12 12
= =
10 10 * 12 120
12
So, 1:10 is equivalent to 120

NOTE

When reducing a fraction, you divide both numerator and denominator by the same
number. This ­process is called cancelling.
When building a fraction, you multiply both numerator and denominator by the
same number.

Changing Fractions to Decimal Numbers

To change a fraction to a decimal number, think of the fraction as a division problem. For
example:
2
means 2 , 5 or 5) 2
5
Here are the steps for this division.

Step 1 Replace 2 with 2.0, and then place a decimal point directly above the decimal
point in 2.0. .
5) 2.0
Step 2 Perform the division twenty divided by five = four.
0.4
5) 2.0 Keystroke
20 sequence:
0 2 5 0.4
2
So, = 0.4
5

Example 1.4
Write 52 as a decimal number.
5
means 5 , 2 or 2)5
. 2
Step 1 2 ) 5.0
2.5
Step 2 2 ) 5.0
4
10
10
0
5
So, = 2.5
2
8 Chapter 1

Two ­Different Keystroke Sequences for Example 1.4:

• 5 2 2.5

If your calculator has a fraction key, you can also use the ­keystroke sequence:

• 5 2 212

Example 1.5
Write 193
10 as a decimal number.

193
means 193 , 10 or 10 ) 193
10
.
Step 1 10 ) 193.0

19.3
Step 2 10 ) 193.0
10
93
90
30
30
0
193
So, = 19.3
10

Two ­Different Keystroke Sequences for Example 1.5:

• 193 10 19.3

If your calculator has a fraction key, you can also use:

3
• 193 10 1910

There is a quicker way to do Example 1.5. To divide a decimal number by 10, move the
­decimal point in the number one place to the left. Notice that there is one zero in 10.
193 193.
= = 193. = 19.3
10 10
To divide a number by 100, move the decimal point in the number two places to the left because
there are two zeros in 100. So, the quick way to divide by 10; 100; 1,000; and so on is to count
the zeros and then move the decimal point to the left the same number of places; the answer
should always be a smaller number than the original number. Check your answer to be sure.

Example 1.6
Write 9.25
100 as a decimal number.

This fraction means 9.25 , 100. There are two zeros in 100, so move the decimal
point in 9.25 two places to the left, and fill the empty position with a zero.
9.25
= 9.25 = 0.0925
100
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 SHUHBA, BATHS AND ROMAN PAVEMENT
Our guide took us straight to the house of the sheikh, who advanced
to meet us with profuse expressions of welcome. Dismounting in the
street, we followed him at his invitation. With difficulty we made our
way dry-shod over a huge pool of rain-water which had collected in
front of the arched doorway, through which we entered a wide
courtyard. To the left stood a rickety erection, in the construction of
which some of the finest materials from the old buildings had been
employed. A broad stairway of large lava blocks led up to it. A roof of
branches and brushwood rested upon gracefully hewn marble pillars,
which were tied together at the top by a rude architrave. These in
turn were supported upon beautiful capitals, turned upside down,
and on carved blocks of stone. The back wall was of the usual mud-
built character, and the pavement was rough in the extreme. A diwân
round three sides doubtless provided sitting accommodation for the
sheikh and his friends in fine weather. Nothing could better mark the
low level of the present inhabitants than their pride in such a bit of ill-
fitting, incongruous patchwork as this, in proximity to the magnificent
remains of a past civilisation.
A strange, rambling old house it was into which we entered by a
narrow winding passage from the left corner of the courtyard. First
we found ourselves in a series of great gloomy apartments
communicating with each other in a line east and west; then, turning
to the right, we scrambled through a doorway, the broken threshold
of which was some feet above the level of the floor; and, pushing
forward, we entered a second courtyard, much smaller than the first,
with rooms all round, on one side two stories high. Some remains of
ancient ornamentation were still visible on the walls, and the
pavement of the yard was evidently from of old. Here were our
quarters for the night, the gentlemen having two little rooms, one of
which served as dining-room, on one side, and the ladies a larger
room on the other. The stair leading up to the gentlemen’s
apartments had been failing for centuries, and now was nigh unto
falling; but, observing great caution, we all escaped without accident.
Our host for this night formed a contrast in every respect to the
dignified and magnanimous chief of Damet el-ʿAliâ. A short, thick-set
man, with stubbly white beard, very red nose, and puffy cheeks, he
bustled about with the air of a man who does a very great favour
indeed. With evident pride he displayed his rooms, and fished for
compliments, suggesting that they were beautiful and clean, mithl
lokanda—“like a hotel.” Ideas of cleanliness differ, but we avoided
controversy by gently turning the conversation to the subject of our
entertainment This we were allowed to provide for ourselves, even to
the coffee, of which he seemed glad to drink a share. He was one of
the less noble sort; and, his people taking their cue doubtless from
their chief, our servants found it difficult to secure all necessaries at
reasonable prices. But as the night closed darkly around us, and the
mountains were alternately lit up by sheets of blinding lightning and
filled with loud rolling thunder, while the rain fell in torrents, and the
wind whistled eerily among the ruins, we were thankful, even with all
its drawbacks, to be under such substantial shelter. If, for reasons
which need not be specified, we slept but little, we could all the more
realise our good fortune, in that, on these high, open uplands, we
were not exposed to the full fury of the tempest.
The morning broke clear and beautiful, and we were out betimes to
make a rapid survey of the old remains. A few paces north of the
chief’s house we struck the main street running east and west. It
seems just possible, from the remains of bases here and there, that
this may once have been a pillared street like that at Jerash, so
striking even in its desolation; or that at Gadara, where the columns
lie prone and broken along the whole length. Following this street
eastward, it sinks rapidly, and passes under a long archway, which
might almost be called a tunnel, strongly built of dressed basalt. This
doubtless formed the substruction of some important public building.
A blacksmith has his workshop in one of the deep cellars in the side
of the archway, and his blazing fire sends cheerful gleams through
the gloom. Beyond this archway eastward lie all the ruins possessing
special interest for the visitor. To the south of the road stands the
great amphitheatre. Carefully built of massive stones, the walls and
tiers of seats are still almost entire. It is the best preserved of all
such structures to be seen east of the Jordan, and it appears to have
been one of the largest. Several poor Druze families were in
possession of the lower parts of the building when we visited it, and
very comfortable houses they made—superior certainly to any of the
modern erections around.
We visited in succession a great sunk octagonal building, as to the
use of which we could make no satisfactory guess; the ruins of
several temples, one of which must have been of no ordinary
splendour; and the remains of the tetrapylon which once graced the
crossing of the two main streets. Now only three of the original four
massive bases are to be seen, and the arches have entirely
disappeared. We scrambled over rickety walls and scattered stones,
and crawled into noisome crypts in search of sculpture and
inscription. We saw enough to persuade us that a rich harvest may
be gathered here by the patient explorer. Of the ancient baths which
stood in the south-eastern quarter not far from this crossing, very
large portions are still in a good state of preservation, and form,
perhaps, the most interesting part of all the ruins.
The material employed in their construction, like that of all the
buildings in the city, is basalt, and in parts the appearance is very
fine; but no adequate idea of their original splendour can now be
formed. The rows of gaping holes in the walls tell of the lining of
marble with which they were once adorned. The destruction of this
was doubtless dictated by the desire to possess the iron fastenings
by which the marble slabs were held in position, and the lead by
which these were fixed into the walls—a temptation which the
cupidity of the Arabs would make it extremely difficult for them to
resist The water channels are skilfully built into the walls, and from
the points at which they project we may guess where the baths were
placed; but the floors are now entirely heaped over with ruins. The
walls are still over thirty feet in height, and of great strength. Most
interesting of all, in connection with the baths, is the old aqueduct, by
which the water was conducted across the low valley to the eastward
from the hills beyond. Several of the substantial arches are still
standing, and the line can be traced away towards the eastern
uplands. Eleven or twelve miles was the water brought to minister to
the comfort of the splendid, luxury-loving Roman.
These and other similarly great structures we owe to the ancients’
ignorance of the principles of hydrostatics. Only when we gaze upon
such vast undertakings, where the channel was raised by artificial
means, so that the water might flow along a regularly inclined plane,
do we fully realise what an immense saving of labour the discovery
of these simple principles has proved to the modern world.
The ancients appear to have spent their strength in the erection of
public buildings. The houses of the common people seem to have
had nothing special about them. Built of the ordinary black basaltic
stone which abounds in the neighbourhood, they have long since
gone to ruin, probably in the shocks of earthquakes. West of the
town stand two beautifully formed conical hills. Some of our party
who ascended them found them to be extinct volcanoes—one
having a circular, cup-like crater in the top. Seen from a distance,
these hills bear a striking resemblance to heaps of grain on a great
threshing-floor. This resemblance has not escaped the sharp eyes of
the imaginative Arabs, who call them “the grain-heaps of Pharaoh.”
Local tradition associates them with the name of a notable oppressor
of the people, the builder of the Qanâtîr Firʿaun (“the arches of
Pharaoh”), the great aqueduct which stretches from the
neighbourhood of Nowa past Derʿat to Gadara. Having exhausted
the people with taxes for the completion of this work, he finally
seized all the grain in the land and stored it here, ready for his own
purposes. He sent a gigantic camel to fetch it, and just as the
unwieldy animal drew near, the wrath of God was kindled against
Pharaoh, and a bolt from the clouds blasted grain and camel
together, leaving two blackened heaps as monuments of the
impotence of all earthly tyrants before the King of heaven.
This town is believed by many to represent the ancient Philippopolis.
True it is that “Philip the Arabian,” a native of this region, having
been elected emperor by the army in Syria about the middle of the
third century—244-249 a.d.—founded a city in his native country,
and adorned it in Roman fashion. But so little is known with certainty
on the subject, that almost any considerable site in Haurân may
claim the honour, if honour it be. The modern name of Shuhba is
said to be derived from the noble Moslem family of Shehâb, who in
the early years of the Mohammedan era came northward from
Arabia Felix, and in their wanderings, before settling in Mount
Lebanon, made this city a temporary home. Relatives of the prophet
of Arabia, they received distinguished honour, and assumed a
leading part in the affairs of the Lebanon. The name of Emîr Beshîr
Shehâb was well known in Europe in the earlier half of the
nineteenth century. This prince of all the Lebanon fell in the year
1840; and the family, already shorn of much of its glory, went finally
down amid the bloody revolutions of 1860.
There is a prevailing belief among the uninstructed in all parts of the
country that the Franj—the name given to all Westerns—are literally
loaded with gold. To this belief we owed a somewhat unpleasant
experience. The avaricious old sheikh took counsel with a faithless
one among our attendants, who evidently wished to smooth the road
for his own return by satisfying the cupidity of the natives at our
expense. He advised the sheikh to demand a most outrageous sum
for our entertainment, in which demand the said faithless one should
support him. The arrangement was at once agreed upon. Meantime
a second attendant, who bore no love to the former, having
overheard the plot, revealed the whole. We decided the amount and
manner of payment, taking care that there should be no reasonable
ground of complaint. Finding himself detected, the sheikh’s
accomplice ignobly forsook him. When the money was put into his
hand, with expressions of thanks for shelter afforded, the old man
could not conceal his surprise, and it was some time ere he
recovered sufficiently to hint that the sum was small. Just before we
started, a few piastres extra were added, to save what little of dignity
he possessed. He, as well as we, wished everything done in secret,
knowing well that a report of his mean conduct spreading among his
brother sheikhs in Jebel ed-Druze would prove fatal to his reputation,
especially as Englîze were in the question. This was the only display
of meanness or stinginess we met with east of Jordan; and for even
this our own servant was chiefly to blame.
 CHAPTER V
Ride to Kanawât (Kenath)—Impressive situation and
remains—Place-names in Palestine—Israelites and Arabs
—Education—A charming ride through mountain glades—
Suweida.
We left the city by the southern, the only double gate the city
boasted, as it is still the best preserved. Here also the city wall is
seen in something like its original proportions. Our way led straight
southwards from the gate, along a track lined on either side with
fallen and broken columns, which showed that the splendour of the
old city had been by no means confined within the walls. A large pool
had formed in the hollow to the right during winter, and, replenished
by the previous night’s rain, afforded refreshment to the horses ere
they faced the steep hill before them. By a zigzag path we soon
ascended to a considerable height, finding far more various
vegetation than we had thought possible.
Riding thus along the western slopes of the mountain, a wonderful
panorama spread out before us: Shuhba, which we had just left,
black and desolate-looking on its blasted hill; the whole extent of
Haurân, el-Lejâʾ, Jaulân, and Gilead; Jebel esh-Sheikh, throwing
high his gleaming shoulders in the north-west; while once again we
could see the Safed hills and the uplands of Lower Galilee, with
Tabor’s rounded cone distinctly visible above his fellows. We could
almost trace all our wanderings from the point where we entered the
Haurân, through the scorched fields of el-Lejâʾ, on to the mountain
over which we were passing. And here it was impossible to avoid
noting once more the dark spots over the far-stretching plains,
marking the positions of ancient towns now waste and ruined. To the
traveller in this country, almost fabulously rich in agricultural wealth,
the phrase “a land of ruins” ever and anon returns like the refrain of
some sad song. A lower road from Shuhba leads by way of Suleim
and ʿAtyl, each with ruins of interest—the former of a temple,
subsequently a Christian church; and the latter of two temples. But it
was much longer, and we feared the hollows would be heavy from
the rain; and wishing to have as much time as possible in Kanawât,
we took the way across the mountain. The immediate surroundings
were dull, but descending a little, and turning a spur of the hill, a
scene of surpassing beauty met our eyes. The valley below opened
into a fair plain, embosomed among the mountains, where teams of
oxen, guided by peasant Druzes, in their white turbans and
tricoloured coats, drew furrows in the soft soil with wooden ploughs,
contrasting picturesquely with the brown and green of the
surrounding slopes. The southern edge of the plain is washed by a
little stream; beyond it the rising ground was covered with glancing
foliage, over which rose the tops of tall columns. Eastward the valley
narrowed, and the stream dashing down a precipice many feet high,
formed a delightful waterfall, on either side of which were gathered
the ruins of Kanawât. The mountains, grey in the changing light,
formed a pleasing background. Just as we swept round in full view, a
light shower drifted down the valley. The sun, striking through the
rain on glistening foliage, white waterfall, and stately ruins on the
brow of the hill, transformed the whole into a vision of fairyland. It
seemed as if the stream of time were suddenly turned back, and the
broken, hoary city on the height smiled again in the beauty and
splendour of her youth. So complete was the illusion, that the
passage of warriors long dead, with the kingly form of Herod in their
midst, hotly pursued by the wild Arabians, would have seemed so
natural as hardly to excite surprise.
We crossed the plain, waded the stream, and climbed the slope
towards the city. Leaving the ruins of a fine temple crowning a leafy
knoll, to the right, we pushed on through thickets of ground oak and
thorn, a strong prickly network of brambles covering all the
undergrowth. The lower part of the town presents nothing distinctive.
It is only partially inhabited by a colony of Druzes. Many of the empty
houses are quite perfect, stone doors and windows in position, and
swinging as easily as they did to the hands of their old possessors.
Going as far as we dared along the edge of the cliff, over which this
part of the town seems to impend, we obtained a fine view of the
gorge into which the waterfall descends, and also of the picturesque
old mill by which the water-power is utilised for the benefit of the
inhabitants. Turning cautiously, we retraced our steps, and entered
the street leading to the sheikh’s house. As he was absent we could
not pay him our respects. An easy ascent leads to the upper town,
where, in open spaces, all the great buildings were gathered. We
crossed the broken remains of a fine old aqueduct, just above the
waterfall, beside the ruins of a gigantic wall; and climbing over
shapeless heaps of stones, many of them beautifully cut and carved,
we entered the largest of all the structures that tell of glories long
waxed dim. It is variously called by the natives es-Seraiah—“the
Palace,” and Makâm Ayyûb—“the place of Job.” Thus, on either side
of the great plain, on which in the far past, as tradition hath it, his
flocks browsed and his husbandmen gathered the golden harvests, a
spot is consecrated to the patriarch’s memory.
 KANAWÂT, RUINS OF TEMPLE
The Seraiah is a group of massive buildings, adorned with
colonnades and artistic sculptures. Around a doorway still almost
entire, opening on a wide paved space, are beautifully carved
bunches of grapes, leaves, and flowers. On the lintel of a door
leading from one part to another, a cross is cut in the stone,
indicating the presence of Christians at some period, while one of
the halls has evidently been used as a church. These apartments
are of spacious dimensions, the smallest of the three measuring
eighty feet by seventy. Most likely they were originally dedicated to
heathen gods. What information as to the ancient city and its noble
buildings may be buried under the great piles of debris no one can
say; but few places, I should think, on either side of Jordan would
better repay the excavator’s toil.
Our cloth was spread on the stump of a fallen column, in the
innermost shrine. Sitting around on huge blocks, finding shelter from
the sun, we enjoyed our mid-day meal. Troops of kindly Druzes
gathered about, ready to bring leban, cheese, milk, bread, or
whatever viands were at their command. The horses, having been
refreshed from the brook, seemed to appreciate the cool shade of
the middle chamber, haltered to the stately columns.
The remains of Kanawât might well engage attention for as many
days as we had hours to spend. On the opposite bank of the deep
valley is a small theatre almost wholly cut out of the solid rock, about
sixty feet in diameter, with a cistern in the centre of the area. A
Greek inscription intimates that it was built by Marcus Lysias,
probably a wealthy Roman officer, for the delectation of the
inhabitants of Canatha. A little higher up stands a temple of modest
proportions, and still further eastward a large tower, resting on
massive substructions, evidently of high antiquity. This is
approached by steps hewn in the rock. Close by is a lofty round
tower, probably sepulchral. Just visible over the oak thickets above
us on our way to Suweida, we saw several similar towers. If we
cannot fix their date, it is clear at least that they belong to a time in
the far past. Of the great reservoirs, whose arched roofs have in
many places been broken through, we could make no minute
inspection. They lie between the Seraiah and the remains of a noble
temple, of which the thick side walls are standing, while in front a few
columns of splendid proportions rise from a huge confused mass of
great stones. It was perilous climbing, many of the blocks being
ready to fall; but the view from the top justified the risk and toil. The
commanding situation of the ancient city is seen to advantage. On a
gentle slope of the mountain, overlooking at no great distance the
wide plain, then as populous as it is desolate to-day, with plentiful
natural supplies of water, rich soil, and thick embowering forests, it
was just such a spot as the splendour-loving Herod might well select
for lavish adornment. Traces of a hippodrome are found close to this
temple, and several of the gardens cultivated by Druzes are
surrounded partly by old walls and partly by new walls of old
materials. The grouping together of so many noble buildings, within
so small space, the graceful shafts of beautiful columns rising in
clusters here and there, reminded one of Athens; but the dark stones
lacked the dazzling effect of the white marbles on the Acropolis.
The name Kanawât probably points to that the city bore ere it fell into
the hands of the conquering Israelites, when it was called Nobah—a
name of which there is now no trace. Before the days of Christ the
old name had reasserted itself, and Josephus calls it Canatha—a
very slight change from the ancient Kenath. The identity of Kanawât
with Canatha is certain. It is interesting to observe, all over Palestine,
this reappearance of ancient names, and the practical obliteration of
those imposed by temporary rulers. The present Beisân is clearly a
modification of the old Bethshean, Scythopolis being forgotten.
Banias is simply the Arabic form of the Greek Panias, the Arabs
having no b; Cæsarea-Philippi is known only to strangers. Beitîn is
evidently another case, representing the ancient Bethaven; while
Bethel is locally unknown. It would be interesting further to inquire
how the characters of the trans-Jordanic tribes affected the
nomenclature of the land. They were essentially a pastoral people.
This tended to cut them off from the other tribes. They never took
kindly to the agricultural life prevalent on the west of Jordan. Their
nomadic habits would leave the captured cities more or less open for
the return of their inhabitants from the fastnesses to which they had
been driven; and of course they would bring the old names with
them. Thus Nobah and Bashanhavoth-Jair are names to be found
only in the Bible records.
The remarkable facial likeness to the Jews found among the people
east of the Jordan leads one to wonder if there is not a closer
relationship than that of cousinship between the two races—if, in
short, the eastern tribes did not in the end mingle freely with their
nomadic neighbours, and thus become gradually alienated in
sympathy from the people and religion of Israel, as they were
already separated from them by the mighty gorge of Jordan. It was
this very calamity the prophetic foresight of their fathers sought to
obviate, when they erected the gigantic altar of witness “in the
forefront of the land of Canaan, in the region about Jordan, on the
side that pertaineth to the children of Israel.” It should be an altar of
witness to succeeding generations of the unity of the people, lest the
children of the tribes westward should be tempted at any time to say,
“What have ye to do with the Lord, the God of Israel? For the Lord
hath made a border between us and you.” The real danger lay in
another direction. Thus there was a certain fitness in the fact that
these eastward tribes were the first to bear the brunt of the great
invasions from the north by which Israel was scourged.
 KANAWÂT, SCULPTURED DOORWAY IN TEMPLE
A Druze villager who attached himself to our company proved a
pleasant and chatty companion. Bright eyes looked out from under
his spotless turban; black whiskers and shining white teeth combined
with a frank, open countenance to prepossess us in his favour. He
said he had been teacher in a school which the Englîze had
supported for some time in the village. By way of corroboration he
aired a few words of English picked up from his superior. Very
strangely they sounded from his lips, without any connection, and
seemingly so out of place amid these surroundings. His
acquaintance with English was like that of a Syrian gentleman friend
of mine, who occasionally in company announces that he knows
English. “What,” he will ask, “is English for Narghîleh?” And without
waiting for reply, exclaims, “Hubble-Bubble!” laughing heartily at his
own joke.
The school had been summarily closed by the authority of the
Government, to the sorrow of the villagers, who were beginning to
appreciate the advantage of a rudimentary education. There is a
great field for missionary enterprise—medical by preference—in all
this region. The missionary’s efforts would find assistance in the
generous instincts of the people themselves. They are yet
uncorrupted by the unhappy influences associated with the passage
of the great travelling public. These are often, unfortunately, all of
civilisation known to the untutored inhabitants; and the barriers thus
raised against the missionary and his work can be fully appreciated
only by those who have had them to face.
Our cheery companion waited until we were all mounted, then led
the way, by many tortuous windings, through the old town, to an
opening which had once been a gate, on the road to Suweida. Few
traces are left of the ancient Roman road, and soon we were on a
track of the usual kind, very soft in parts, from the recent rains. We
passed between fruitful vineyards and cultivated patches, where the
white turbans of the vine-dressers moved to and fro among the
green with pleasing effect. Our ride that afternoon along the hillsides,
through oak and thorn thickets, the green interspaces sprinkled with
flowers, openings in the foliage affording glimpses of the wonderful
plains of Bashan, was the most agreeable by far of all we enjoyed in
Haurân. The freshness of the leaf, the music of the birds, and above
all, the cool breeze that met us, almost persuaded us that the Orient
was but a dream, and that we were traversing an upland in Bonnie
Scotland.
Through a break in the forest we descried our tents, pitched on the
green sward, and ready for our reception, beside a curious-looking
block of masonry. Then sweeping round into the open, we obtained
our first view of Suweida, lying darkly on the farther bank of a little
ravine, by which it was separated from our camping-ground. The
roofs were alive with men straining their eyes in our direction. Our
advent clearly caused no small stir in that remote town. Arriving at
our tents, we found a large company assembled to survey us. They
watched all our movements with an amused curiosity, like that of
children in a menagerie. We were in time to witness the sunset, and
in the calm cool air were tempted to watch how long he took to
disappear, from the instant when his under rim touched the horizon.
We looked earnestly, and seemed relieved when at last he vanished.
Our observers, I am sure, entertained a shrewd suspicion that some
remnants of sun-worship still lingered among these curious
westerns. Little thought they how our hearts followed the departing
beams to the land where, in the slant rays of the longer evening,
dear ones sat musing, drawing vague pictures of regions famed in
sacred story, and praying the Father of all, the light of whose eye
fades not from earth like the passing day, to guard the wanderers
from peril.
 CHAPTER VI
Healing the sick—A strange monument—Telegraph and post
in Haurân—Cruel kindness—The Ruins of Suweida—
Turkish methods of rule—ʿIry—Sheyûkh ed-Druze—
Jephthah’s burial—Enterprise of Ismaʾîl el-ʿAtrash.
Here, as at every point touched in our journey, we had ample
evidence of the prevalence of sickness and suffering, and of the
crying necessity for competent medical aid. The weak and diseased
are a prey to every travelling quack, and they bore in their bodies
only too convincing proof of their simple-hearted confidence in men
who professed to be able to relieve them. Ruined eyes and maimed
limbs told only too plainly what havoc unscrupulous men work
among these trustful people. The quack hopes to pass but once in
any given way, and cares but little for the results of his operations if
only he make present gain. The name of the good doctor wrought
like magic. Almost before we could realise it the camp was
surrounded by patients; a motley gathering they were—Moslem,
Druze, and Christian; men, women, and children, of all ages, clad in
richly varied costumes; they came forward, one by one, to tell of their
sufferings, and receive what help was possible. Not unpleasantly the
time passed, examining antique coins, making cautious purchases,
and engaging the more intelligent in conversation about their town
and district, until the cheerful voice of the dinner-bell summoned us
within.
With the morning we were able to see the strange tower under
whose shadow we had slept. It is reputed one of the oldest
monuments in the country. According to inscriptions, Greek on one
side and Palmyrene on another, it was built by one Odainatus to the
memory of his wife Chamrate. The building is over thirty feet square,
and rests on a base, to which a couple of steps lead up. Between the
Doric pilasters that adorn the sides, the monument is ornamented,
as became the tomb of a soldier’s wife, with emblems, in relief, of
military accoutrements. The top of the monument is now a heap of
confused blocks, while many great stones, rolled down, lie in utter
disorder to the south-west. The name Debusîyeh, by which it is
known among the natives—“the pin-shaped”—shows that it was,
probably at no remote period, finished off in a pyramid. The evil that
has befallen it may be due to some thought that buried treasure
might be found there. In these circumstances no structure would be
safe from the destroying hands of the Arabs. It has been thought that
the monument dates from not later than the first century of our era,
and that therefore this Odainatus was not the warrior husband of the
famous Zenobia, ruler of Palmyra. The Odainatus known to history
was in these parts; and there is nothing impossible in the supposition
that the glories of the campaign may have been dimmed for the
chivalrous soldier by the death of his sweet companion, ere the star
of Zenobia arose in the heaven of his love. This would bring the date
down past the middle of the third century. The conjecture is so far
supported by the presence of the inscription in Palmyrene. Withal it
is the most interesting of all the remains of the past now to be seen
in Suweida and its neighbourhood.
Descending the steep bank, we crossed by an ancient bridge the
little stream that flows in the bottom of the ravine. With the advance
of summer this stream soon vanishes, and the town becomes
entirely dependent for water supply on reservoir and cistern. At the
gate of the town we found a little guide who conducted us to the
post-office. The quarters occupied as imperial post and telegraph
office would horrify the humblest of our Western officials. We
scrambled over several dunghills and broken walls, and but for the
telegraph wires it would have been impossible to distinguish the
“office” from a number of rude cattle-shelters around. The maʾmûr,
or official in charge, was all politeness and courtesy. Learning that a
mail was about to be despatched to the north, we set about writing
pencil-notes to our friends, while the maʾmûr, business being slack,
engaged in a conversation by telegraph with his brother operator in
Damascus, securing for us information on several points of
importance. The amount of telegraphing thus done for the friends of
the maʾmûrîn in Syria would not be readily credited in the West. A
message is sent to bring one to the office, when, if nothing special is
on hand, he may hold a long conversation on any subject with his
friend or man of business at a distance. These maʾmûrîn in Syria are
almost all Christians, Moslems possessing the requisite
qualifications in linguistic attainments and intelligence being seldom
available. This speaks volumes for the system of education
inaugurated and carried on chiefly by the missionaries, of which as
yet few Moslems have taken advantage. The position of clerk in very
many of the various Government departments is also occupied by
Christians. Moslems in the country are, however, slowly awakening
to realise the advantages of education, and are seeking in greater
numbers than ever to avail themselves of opportunities hitherto
despised.
The Druze sheikh of the town, who was also kaim makâm, or
lieutenant-governor of the district, we found in his own house near
the top of the quarter at present inhabited. He was in sore distress
over the apparently hopeless illness of his son, a lad of some twenty
summers, who sat suffering among his friends. The room was
crowded in every part by relatives and friends, who had come from
far and near to show their sympathy in the hour of trial. Anything
more completely opposed to all humane and civilised ideas of the
conditions that ought to prevail in a sick-room it is impossible to
imagine. The air was foul with many breaths, and laden with the
fumes of tobacco, in which all seemed to indulge, conversation being
carried on in manner and tone suggestive of the public market; the
dying youth, meanwhile, utterly wearied of the noise and confusion,
with difficulty attracted attention to have his few wants supplied. It
must not be thought that this conduct was the result of exceptional
thoughtlessness on the part of the sheikh’s sympathisers. It was all
done in obedience to custom, whose requirements are far more
stringent than those of written law in this country. The man whose
sick-room is not crowded with hosts of sympathising friends is held in
but little respect. To refrain from mingling with the crowd and adding
a quota to the hubbub is to prove lack of all interest in the case. So
firmly is the custom rooted, that the energetic efforts of enlightened
medical men in many parts have as yet produced almost no
appreciable result. We long for quiet in our time of trial, and true
friends jealously guard against intrusion upon our grief. Here trial
and sorrow must alike be borne practically in presence of the public.
When death enters a household the place is literally taken
possession of by so-called sympathising friends; and their well-
meant endeavours to divert the thoughts of the mourners from their
loss must nearly always have the effect of deepening the woe they
are intended to alleviate.
The sheikh’s house, less squalid perhaps than most in the town, was
built around a paved courtyard, entered from the street by an
imposing doorway. One large room had also a door opening upon
the street, approached by a flight of steps. Here we were entertained
with coffee. As a Government official who had received instructions
from his superiors to receive the travellers with all courtesy, the
sheikh bore himself with no little dignity; and only the haste of our
departure prevented his making a larger display of hospitality. The
diwân of the sheikh stands on the opposite side of the street a little
lower down, on the site of an ancient temple. Many of the columns
which once surrounded the latter are standing still, but serve only to
cast a dreary air of departed glory over the place. A few paces
farther down, the street is spanned by a triumphal arch, of Roman
workmanship. This street is paved throughout. We visited, in rapid
succession, the remains of a church, of a mosque, and of a building
called by the natives el-Mehkemeh—“the court of justice.” All of
these are in a completely ruinous condition. Suweida offers a rich
field for inscription-seekers. Only he who would make thorough work
must be prepared for risks and unpleasantnesses,—in hanging, for
example, over the top of a rickety doorway to read an inscription
placed upside down, or in creeping into holes and cellars where
one’s attention is almost entirely absorbed in the important but well-
nigh impossible process of breathing. Here are also the remains of a
nymphaeum and aqueduct dating from the time of Trajan. Two large
reservoirs afford the chief supply of water, there being no fountains
in or near the town. These are built round with solid masonry, and
the water is reached by means of stone stairs. When the summer is
well advanced, it must require a stout heart and no little usage to
enable one to conquer a natural repugnance to the unwholesome
liquid collected in these reservoirs. I imagine that the memory of the
oldest man does not carry him back to the time when they were last