NUR 205: ADVANCED

NURSING I
BY
William Wilberforce Amoah
(MPhil, EN, BSc, RGN)
0505253876
amoahwilliam32@yahoo.com
DRUG DOSAGE CALCULATIONS
 DRUG DOSE CALCULATIONS
• A drug dose is the specific amount of
medication to be taken at a given time.
• The usual recommended adult dose of
medication, as found in standard references, is
based on the assumption that the patient is a
"normal" adult. Such a "normal" (or average)
adult is said to be 5 feet 9 inches (173
centimetres) tall and weigh 154 pounds (70
kilograms)
• However, many people do not fit into this
category
• The branch of medicine/pharmacy that deals
with the study of doses is known as Posology:
(Derived from the greek posos, how much,
and logos, science)
• Types of doses
– The usual dose of a drug: This is the amount of drug
expected to produce an effect on the condition it is
officially recognized to treat.
– Range of usual dose of a drug: The dose of a drug is
usually expressed as a range. The minimum dose or
the lower limit of the dose is essential for eliciting an
intended therapeutic response whereas the
maximum dose or the higher limit of the dose is the
amount of the drug substance that can be tolerated
by an average individual. Under dosage is when a
lower than minimum dose for that condition is given
while overdosage when amount of drug in excess of
the maximum dose is administered.
– Dosage regimen: The schedule of dosing of a drug (twice
a day for 10 days) is known as the dosage regimen.
Beside the dose of the drug, the schedule of
administration is important since it determines whether
a satisfactory therapeutic plasma concentration of the
drug is achieved and maintained over the acceptable
period of treatment of the condition.
– Loading/priming/initial dose: This is a large than normal
dose of a drug is initially administered to enable a peak
plasma concentration is attained within a shorter period
and the therapeutic plasma drug concentration is
maintained through subsequent administration of
scheduled doses known as maintenance doses. e.g.
digoxin (cardiotonic agent) can be Initially administered
four or more times a day, followed by a single daily dose
to maintain the desired blood level of the drug.
– Maintenance dose: This is smaller and equal
doses that are administered at appropriate
frequencies to maintain the plasma concentration
of a drug after a loading dose had been earlier
administered.
– Prophylactic dose: This is a dose that may be
administered to protect the patient from
contracting a specific disease, such as vaccines.
– Therapeutic dose: This dose is that which is
administered to a patient after exposure or
contraction of the disease.
 Factors that influences dose of a drug
• The two primary factors that determine
or influence the dose are age and
weight; but there are several others such
as
– Gender
– Surface area (in children)
– Time of administration
– Immune response
– Tolerance/Habitual use
– Pathological factors
 – Psychological factors
– Genetic make-up (nationality, ethnic heritage)
– Occupation
– Frequency of administration
– Route of administration, etc
• We shall discuss some of these factors into a
little more detail
• Weight
– Obese (overweight) patients may require more
medication than thin patients may require because
the drug has more tissue to which it can go into.
– The drug concentration at site of action is based on
the ratio between the amount of drug administered
and size of the body
– The dosage of many drugs is calculated on a weight
basis. For example, a person might be prescribed a
drug that has a dosage of 5 milligrammes of drug
per kilogramme of patient body weight.
• Age
– As a rule, the very young and the elderly require less
than the normal adult dose of most medications.
– Part of this requirement for less medication is due
to the altered metabolism of the drug. Since body
enzyme systems greatly influence drug metabolism,
considering the differences in these enzyme
systems, doses based upon age is important. In the
infant, some enzyme systems are not yet fully
developed. On the other hand, the enzyme systems
of the elderly may not function as well as in the
past.
– Glucuronidation takes 3 months to develop in a
newborn.
• Surface area
– A person's height and weight are related to the
total surface area of his body. The "normal"
(average) adult has a body surface area of
approximately 1.73 square meters. A nomogram
is used to determine the surface area of a patient.
The dosage of certain drugs (for example, some
anticancer drugs) is determined by the patient's
body surface area.
• Sex
– Physiological differences between the sexes may
influence the dose or the requirement for drugs.
– Women usually require smaller doses than men not
only because of their average smaller stature and
quieter life, but also because of their greater
susceptibility to many influences.
– Sometimes however, females may require larger doses
especially for drugs which are lipophilic because they
have proportionately more fat tissue than males.
– Moreover, oestrogen and testosterone, are two sex
hormones that can affect the patient’s rate of
metabolism which can, in turn, influence the rate at
which a drug is metabolized, absorbed, or excreted from
the body.
– Testosterone increases the rate of metabolism of
drugs
– Females are more susceptible to autonomic drugs
(oestrogen inhibits choline esterase).
– The requirement for iron is much higher in the
female than in the male, because of the loss of
blood in each menstrual cycle.
Sex based differences in drug activity (Am Fam
Physician. 2009;80(11):1254-1258.)
– Physiologic differences between men and women affect
drug activity, including pharmacokinetics and
pharmacodynamics.
– Pharmacokinetics in women is affected by lower body
weight, slower gastrointestinal motility, less intestinal
enzymatic activity, and slower glomerular filtration rate.
– Because of delayed gastric emptying, women may need to
extend the interval between eating and taking medications
that must be absorbed on an empty stomach.
– Other physiologic differences may affect medication
dosages. For example, because renal clearance is slower in
women, some renally-excreted medications, such as
digoxin, may require a dosage adjustment .
– Pharmacodynamic differences in women include
greater sensitivity to and enhanced effectiveness of
beta blockers, opioids, selective serotonin reuptake
inhibitors, and typical antipsychotics.
– Additionally, women are 50 to 75 percent more likely
than men to experience an adverse drug reaction.
– Because women are prone to torsades de pointes, (a
specific type of abnormal heart rhythm that can lead
to sudden cardiac death) medications (eg
clarithromycin, levofloxacin, haloperidol) known to
prolong the QT interval should be used with caution.
– Women should receive lower dosages of digoxin and
have lower serum concentration targets than men
because of higher mortality rates.
• Physical conditions of patient
– The physical condition of the patient influences
how a particular drug might act. Consequently,
the weak or debilitated patient might require
smaller doses of some medications. Patients who
are in extreme pain may require larger doses of
analgesic agents than those patients who are in
less pain.
– Debilitated and anaemic patients are, in general,
more sensitive to the toxic effects of drugs and
hence they are given smaller doses
• Psychological condition of patient
– The patient’s attitude about his disease or
treatment can influence the effectiveness of a
drug.
– It has been shown that patients receiving placebo
tablets (tablets that contain no active ingredient)
sometimes have the same side effects as the
patients who were taking tablets of the same
appearance that did contain the drug. In some
cases, both types of patients (those taking the
placebo and those taking the drug) recovered at
the same time.
• Tolerance/Habitual use
– The therapeutic effects of some drugs are lessened in
individuals after the drugs have been used for long
periods. Thus, an individual who has used such a drug
for a long time needs larger doses of the drug than he
did when he first began, in order to obtain the same
effect. This effect is called tolerance.
– Persons who use opium, heroin, cocaine,
amphetamines, and barbiturates develop a tolerance to
these substances.
– Cross-tolerance occurs when the use of one drug
causes a tolerance to another drug. Alcoholics,
barbiturate addicts, and narcotic addicts develop a
cross-tolerance to sedatives and anaesthetics.
• Time of administration
– The time at which a drug is administered is
important.
– Some orally administered medications should be
taken before meals (that is, on an empty stomach)
to increase the amount of drug absorbed into the
system.
– Other oral medications (that is, those that cause
irritation to the gastrointestinal tract) should be
taken after meals on a full stomach.
• Occupation
– Persons working in strenuous jobs may require
larger doses than those who sit at a desk all day.
• Frequency of administration
– A drug given frequently may need a smaller dose
than if administered at longer intervals.
– Biological half-life of a drug is the main factor
determining frequency of drug administration. For
example, if the biological half-life of sulphadiazine
is 4 hours, 1 g of the drug has to be given every 4
hours after initial dose of 2 g.
– However, for some other drugs, the biological half-
life has no relation to frequency of administration.
eg. Reserpine used as a tranquiliser.
• Route of administration
– In general, the rapidity of absorption of a drug
decreases with route of administration in the
following order: Intravenous > Intramuscular >
Subcutaneous > Oral.
– Thus, in general, intravenous dose of a drug is smaller
than its intramuscular or subcutaneous or oral dose.
– Example : Doses of ergotamine for various routes are
as follows.
• Oral : 2 to 5 mg
• Intramuscular : 1 mg (about to 1/2 of oral dose)
• Intravenous : 0.25 mg (about to 1/8 of oral dose and 25%
of IM dose)
• Pathological factors
– If the organs, through which biotransformation or
excretion takes place, are diseased then smaller
dose is indicated. For example, in case of renal
insufficiency, phenobarbitone (mainly excreted by
the kidneys) should be given in smaller dose and
in case of patients suffering from liver diseases,
morphine should be given in smaller dose
(morphine is mainly inactivated in liver).
– Aspirin has no effect on normal body temperature
but lowers the body temperature in fevered
patients.
• Genetic makeup
– Another reason for different responses to a
medicine is due to variations in genetic make-up.
Most of these genetic differences are complex
and are difficult to determine with any degree of
certainty; but a few genetic differences are well
documented.
– One genetic trait that has been well documented
is the difference between what are called slow
and fast acetylators. Slow acetylators break down
certain medicines at a very slow rate while fast
acetylators break down the same medicines much
more quickly.
– Among the drugs that are metabolized differently
by these two groups are an antitubercular drug,
many sulpha drugs used to treat bacterial
infections, and hydralazine, a drug that helps
control the heart-rate.
– Generally, about 60% of people of European and
African ancestry are slow acetylators with the
remaining 40% being fast acetylators. However,
the percents can vary somewhat by country and
latitude. For example in Africa, a study of
Ugandans indicated that between 49% and 61%
are slow acetylators, while a study of Egyptians
indicated that between 72% and 94% are slow
acetylators.
 Drug measurement systems
• The three (3) measurements most often used in clinical
situations are:
– Metric system- This is the commonly used method in the
hospital.
• The metric system uses the gramme as the basic unit of
solid measure and the litre as the basic unit of liquid
measure. The unit for length is metres. There are
subunits such as millilitre (mL) which has same value as
cubic centimetres (cc) i.e, 5 mL is same as 5 cc. The
subunits of mass measurement of drugs can be
milligrammes (mg) or micrograms (mcg).
• It was first developed by the French.
• To prevent the mistake of overlooking a decimal point,
precede the decimal point with a zero if the value is less
than one, i.e., writing 0.8 g is better than .8 g.
– Apothecary system- The apothecary system is a
very old system or measure that was specifically
developed for use by apothecaries or
pharmacists.
• The apothecaries’ system has units for weight
and volume only. The minim is the basic unit of
liquid measure and the grain for solid measure.
It also has units such as ounces, fluid ounces,
pounds, pints, etc.
• Though obsolete, some of these units are still
used in some measurement. One pint is
equivalent to 500 ml. 12 ounces make 1 pound
– Household system- This involves the use of
household measuring devices such as spoons,
wine glass and coffee cups .
• The usual units are drops, teaspoons,
dessertspoons, as well as tablespoons.
• Approximately, one teaspoon =5 ml, while
dessertspoons = 10 ml and tablespoons =15 ml
respectively.
• 16 tablespoons equal 1 cup, etc.
– Other measuring system include
Avoirdupois system
• The avoirdupois system is another older system
that was very popular when pharmacists
routinely had to compound medications on
their own.
• This system uses ounces and grains, but they
measure differently from those of the
apothecary and household systems.
• The avoirdupois system is seldom used by
prescribers but may be used for bulk
medications that come directly from the
manufacturer.
• Units
– Some drugs are measured in units other than those
already discussed.
– These measures may reflect chemical activity or biological
equivalence. One of these measures is the unit (U).
– A unit usually reflects the biological activity of the drug in
1 mL of a solution. The unit is unique for the drug it
measures; a unit of heparin would not be comparable to a
unit of insulin.
• Milliequivalents
– Milliequivalents (mEq) are used to measure electrolytes
(eg, potassium, sodium, calcium, fluoride).
– The milliequivalent refers to the ionic activity of the drug
in question; the order is usually written for a number of
milliequivalents instead of a volume of drug.
• International Units
– International units (IU) are sometimes used to
measure certain vitamins or enzymes.
– These are also unique for each drug and cannot
be converted to another measuring form.
 Dosage calculations
• A calculation is required to determine the patient's dosage from
general dosage information or when the prescribed or required
dosage does not match the available dosage. For instance, the
condition requires 500 mg of a drug in tablet form but the
strength available or on hand is 250 mg per tablet. If the
required dose is the same as the strength available then there
will no need for calculation.
• These mathematical calculations ensures the right amount of
medication will be administered to the patient to ensure quality
healthcare and also prevent medication administration error.
• 3 basic methods useful in the calculations for dosage forms such
as liquids, capsules or tablets
• Basic formula method,
• Ratio and proportion
• Fractional method.
Basic Formula Method
• Though there are other methods of calculating the dosages for clients as
stated above, the Basic formula method will adequately ensure correct
dosage calculations if applied correctly. The formula is stated as below;
D
֜ xV=G
H
•

– D = Desired dose. This is the dose ordered by the physician or the

required dose that will be given to the patient at a time
– H = Dose on hand or available dose. This is the dose on the drug label
or the amount the whole drug comes with. Eg 200 mg/tablet or 125
mg/5 ml
– V = Unit or volume available or volume on hand (Eg. If the available
drug is X mg/ tablet, or X mg/capsule, V is 1. If the drug is a liquid
preparation and strength is X mg/5 ml or 1000 units/ml, V is 5 and 1
respectively.
– G = The amount of drug to be administered
 Examples
• As a Nurse you were ordered to give 25 mg of
Benadryl to a patient with itching and hives.
Benadryl is supplied 50 mg/ 2 cc. What is the
desired dose that should be administered?
• Solution: D = 25 mg , H =50 mg V = 2 ml G =?
ml
=G
1 mL which is same as 25 mg of the Benadryl
will be administered.
• A nurse is to administer 25mg of a medication.
The Dose on hand is 50mg per tablet. How many
tablets would the nurse administer?
• Solution: D = 25mg, H = 50mg , V = 1tablet
G tablets = ?
=G =G

G = 0.5 tablet or tablet

– Some tablets are scored to ensure that breaking is
easier.
• You were ordered to give 1 g of Keflex for a patient.
Keflex was available in 250 mg per capsule. How many
capsule should the patient be given.

• Solution: D = 1 g = 1000 mg, H = 250 mg, V = 1 capsule

D = 1gm (Note: convert the grammes to milligrammes) 1 g =
1000 mg

=G

G = 4 capsules. Patient will require 4 capsule of Keflex

• You ordered a nurse intern to give 500 mg of
Paracetamol to a child p.o. The Paracetamol syrup is
available in the strength of 125 mg/5 ml. How many
teaspoons will the nurse intern administer assuming
the medicine did not come with a measuring cup.
• Solution: D = 500 mg , H = 125 mg , V = 5 mL, G =? mL

=G

The volume of syrup is 20 mL which is equivalent to 4

teaspoons. One teaspoon is 5 mL.
 Trial questions
• Heparin 800 U is ordered for a patient. The heparin is supplied in a multidose vial that is
labeled 10,000 U/mL. How many cubic centimeters of heparin would be needed to treat
this patient?
a. 0.8 cc
b. 0.08 cc
c. 8.0 cc
d. 0.4 cc
• Aminophylline is supplied in a 500 mg/2.5 mL solution. How much would be given if you
ordered 100 mg aminophylline IV?
a. 5 mL
b. 1.5 mL
c. 2.5 mL
d. 0.5 mL
• You were ordered to administer Digoxin 0.125 mg for a patient who is having trouble
swallowing. The bottle of digoxin elixir reads 0.5 mg/2 mL. How much would you give?
a. 5 mL
b. 0.5 mL
c. 1.5 mL
D. 1 mL
Heparin injection
• INTRAVENOUS FLOW RATE CALCULATION
– Some medications must be administered by
intravenous route to ensure rapid delivery.
– Medication orders must indicate an
administration of the specific intravenous solution
over a number of total hours.
– Intravenous fluid must be given at a specific rate,
neither too fast nor too slow.
– The specific rate may be measured as ml/hour,
L/hour or drops/min.
– To control or adjust the flow rate, only drops per
minute are used.
– The burette contains a needle or plastic dropper
which gives the number of drops per ml (the drop
factor). A number of different drop factors are
available (determined by the length and diameter
of the needle) which may be indicated on the
infusion set. Common drop factors are: 10
drops/ml (blood set), 15 drops / ml (regular set),
60 drops / ml (microdrop).
 The formula for calculating flow rate is as stated below;

𝑔𝑡𝑡𝑠
𝑉𝑜𝑙𝑢𝑚𝑒 ሺ𝑚𝑙 ሻ 𝑥 𝐷𝑟𝑜𝑝 𝑓𝑎𝑐𝑡𝑜𝑟 ( )
𝑚𝑙 = 𝐷𝑟𝑜𝑝 𝑟𝑎𝑡𝑒/𝐷𝑟𝑖𝑝 𝑟𝑎𝑡𝑒/ 𝑓𝑙𝑜𝑤 𝑟𝑎𝑡𝑒 (𝑔𝑡𝑡𝑠/min⁡)
𝑇𝑖𝑚𝑒 (min )
Examples
You were ordered to give 1500 ml IV Saline is
administered to a patient over 12 hours. Using a drop
factor of 15 drops / ml, how many drops per minute
need to be delivered?
Solution
Volume = 1500 ml
Drop factor = 15 drops/ml
Time = 12 hours (must be converted to minutes by multiplying by 60 minutes)
• You were to give a patient IV ,1000 millilitres of 5% D/W.
The flow rate is 36 drops per minute. If the drop factor is 10
drops per millilitre, how many hours will it take this IV to
finish

• Solution
Volume = 1000 ml, Flow rate = 36 gtts/min, Drop factor = 10 gtts/ml

Time = 277.78 min = hours

Time = 4.6 hours
 Trial questions
• You ordered a nurse intern to give 500 mL LR to be infused over 2
hours. Available is a 15 gtt IV tubing set. How many gtts/ minute will
be administered?
• Calculate the IV flow rate for 500 mL D5W to run for 8 hours. The
drop factor is 60 gtt/mL.
• Calculate the IV flow rate for 200 cc of 0.9% NaCl IV over 2 hours.
The drop factor is 20 gtt/mL.
• The order written for 1000 mL of normal saline to be administered
over 10 hr. The drop factor on the IV tubing states 15 drops/mL. What
is the IV flow rate?
a. 50 mL/ hr at 50 drops/min
b. 100 mL/hr at 25 drops/min
c. 100 mL/hr at 100 drops/min
d. 100 mL/hr at 15 drops/min
 Paediatric Dose Calculations
• Children require different dosages of most drugs than adults
do. The “standard” drug dosage that is listed on package
inserts and in many references refers to the dose that has
been found to be most effective in the adult male.
• An adult’s body handles drugs differently and may respond
to drugs differently than a child’s. A child’s body may handle
a drug differently in all areas of pharmacokinetics.
• The responses of the child’s organs to the effects of the drug
also may vary because of the immaturity of the organs.
Most of the time a child requires a smaller dose of a drug to
achieve the comparable critical concentration. On rare
occasions, a child may require a higher dose of a drug.
• For ethical reasons, drug research per se is not done
on children. Over time, however, enough information
can be accumulated from experience with the drug to
have a recommended paediatric dosage.
• The drug guide that you have selected to use in the
clinical setting will have the paediatric dose listed if
this information is available.
• Sometimes there is no recommended dosage but a
particular drug is needed for a child. In these
situations, there are established formulae that can be
used to estimate the appropriate dosage. These
methods of determining a paediatric dose take into
consideration the child’s age, weight, or body surface.
• Fried’s Rule applies to a child younger than 1 year of age.
The rule assumes that an adult dose would be appropriate
for a child who is 12.5 years (150 months) old.
Fried’s Rule states

• Young’s Rule, which applies to children age 1 to 12 years

of age, states

• Clark’s Rule uses the child’s weight to calculate the

appropriate dose and assumes that the adult dose is based
on a 150-lb person. It states
• Body Surface Area Basis
- Most drugs in children are dosed according to body
weight (mg/kg) or body surface area (BSA) (mg/m2). If
weight is recorded in pounds, then care must be taken
to properly convert body weight from pounds to
kilogrammes (1kg = 2.2lb) before calculating doses
based on body weight. The British National Formulary
and many reference textbooks recommend that drug
dosages for children be calculated according to body
surface area (BSA). Although many rules for drug
dosage have been developed based on age, weight and
surface area, none has been accurate and simple
enough for routine use.
- The formula for child’s dose using the BSA is
• To determine the Surface area requires the use
of the nomogram
• Therefore the simplified rules for calculation of
dosage based on body surface area are as
follows;
– For a child up to 30 kg, drug dose may be = (wt x 2)%
of an adult dose;
– Over 30 kg, child’s drug dose = (wt + 30)% of an adult
dose.
– If this percentage of an "adult" dose of a drug is
used, not only is the BSA curve followed more closely
than with the conventional mg/kg regimen, but
fewer major errors of prescription may be expected.
• For instance, the maximum daily adult dose of a drug is 1500 mg. What will
be the maximum daily dose of a child weighing
(i) 25 kg
(ii) 45 kg
• Solution
(i)
– Child weighs less than 30 kg,
– Therefore dose = (wt x 2)% of adult dose
= (25 x 2)% of 1500 mg
= 50% of 1500 mg
= 750 mg
The child’s maximum daily dose of the drug is 750 mg
(ii)
– Child weighs more than 30 kg
– Therefore dose = (wt + 30)% of adult dose
= (45 + 30)% of 1500 mg
= 75% of 1500 mg
= 1125 mg
The child’s maximum daily dose of the drug is 1125 mg
• BODY WEIGHT BASIS
– Though not as reliable as the BSA method above,
paediatric drug doses or even some adult doses are also
be calculated based on the body weight. With the weight
of the patient known and dosage specified in terms of
weight, the necessary dosage can be calculated going
through a few steps of calculation and the use of a
formula as stated below;

– The specific amount to be administered can then be

calculated using the Basic formula method for calculating
dosages as explained earlier;
 Examples
• Calculate the dose of amoxicillin suspension in
ml for a 1yr old child weighing 22 lb. The dose
required is 40mg/kg/day, to be given in two
divided doses. The suspension comes in a
concentration of 400mg/5ml
• Solution
– Step 1
• Convert pounds to kg: If weight is already in kg there
will be no need for step 1
• Step 2
– Calculate the required dose in mg: The formula then comes into
play 10kg x 40mg/kg/day = 400mg/day
– If only the required daily dose is required, the calculation ends
here. But other steps come in if it is a divided dose,
• Step 3
– Divide the required daily dose by the frequency: In this case,
BID, that is twice daily
– 400mg/day ÷ 2 = 200 mg required at each of the two doses.
• Step 4
– Amount to be administered is then calculated
D = 200 mg, H = 400 mg/5 ml, V = 5, G = ?? ml

– Therefore 2.5 mL bid will be administered

 Trial questions
• Calculate the dose of ceftriaxone in ml for a 5yr old
child weighing 18kg. The dose required is
100mg/kg/day given IV once daily and the drug
comes pre-diluted in concentration of 40 mg/ml.
Answer = 45 mL to be administered daily
• A medical assistant (MA) orders 200 mg of Rocephin
to be taken by a 7 kg infant every 8 hours. The
medication label shows that 75-150 mg/kg per day
is the appropriate dosage range. Is this MA’s order
within the desired range?
THANKS FOR YOUR
ATTENTION