NUR2047 Pharmacology Basic Concept & Dosage Calculation PDF

NUR2047 Pharmacology Basic Concept + Dosage Calculation Winsy WAN Basic Concept Drug Names Drug Effects Therapeutic Side effect Adverse drug reactions Drug allergy Drug Interactions Pharmacodynamics Pharmacokinetics  Overview Pharmacolo...

NUR2047 Pharmacology Basic Concept + Dosage Calculation Winsy WAN Basic Concept Drug Names Drug Effects Therapeutic Side effect Adverse drug reactions Drug allergy Drug Interactions Pharmacodynamics Pharmacokinetics  Overview Pharmacology 藥理學 ~ the study of the effects of drugs Medication on the function of living systems Chemical compound / substance for administered for diagnosis, prevention, Pharmacy ~ cure, treatment or relief of a symptom or the place for preparing, for prevention of disease compounding, and dispensing drugs. Prescription Written direction for the preparation and Pharmacist ~ administration of a drug by WHO? the man that prepares, makes, and dispenses drugs as ordered by a physician/ dentist.  Acetaminophen (paracetamol撲熱息痛) (generic name) Drug Names = Panadol 必理痛 (brand name) = Fortolin 幸福止痛素 (brand name) Chemical names Brand name 品牌名 / Trade describes drug structures, based name/ proprietary name on the atomic/molecular usually short, easy to remember structure/ functional group of One drug may be drug, seldom used in medical manufactured by several practice companies, have several trade names Drug Names Generic name 通用名 (+)-3-(4-Chlorophenyl)-NN- assigned by manufacturer dimethyl-3-(2-pyridyl)propylamine (approval by regulatory body) hydrogen maleate used throughout drug’s lifetime = Chlorpheniramine Meleate Selected & recognized internationally 扑爾敏胺 (generic name) A drug has only one generic name = Piriton (brand name) Drug Effect Drug Effects - Therapeutic 治療效果 Expected Therapeutic effect = Desired effect MUST KNOW: Reason (Primary effect) for drug prescription Types of drug Description Palliative Relieves symptoms of diseases but does not affect the disease itself Curative Cures a disease or condition Supportive Supports body function until other treatments or the body’s response can take over Substitutive Replaces body fluids or substances Chemotherapeutic Destroys malignant cells Restorative Returns the body to health Drug Effects Side effect 副作用 Un-intended, usually predictable An adverse drug reaction / side effect is a harmful, undesirable response. It can be mild to severe. Adverse drug reactions 不良藥物反應 Secondary effects / extra effect ○ A drug produces not only a major therapeutic effect but also additional, secondary effects that can be harmful or beneficial. ○ Example 1: Morphine used for pain control can lead to two undesirable secondary effects: constipation and respiratory depression. ○ Example 2: Diphenhydramine used as an antihistamine produces sedation as a secondary effect and is sometimes used as a sleep aid. More Terms …… Augmented 增強型 reactions / drug toxicity / toxic effects Hyper-susceptibility敏感度 patient has altered pharmacokinetics (absorption, metabolism, and excretion), which may lead to higher-than-expected blood concentration levels Increased receptor sensitivity also can increase patient’s response to therapeutic or adverse effects; or Impaired metabolism or excretion. Cumulative effect is the increasing response to repeated doses of a drug that occurs when the rate of administration exceeds the rate of metabolism or excretion → amount of the drug builds up in the blood Such a patient experiences an excessive therapeutic response or secondary effects even when given the usual therapeutic dose. Thus, toxic symptoms may occur. To avoid toxic reactions, We need to know patient’s profile!!! chronically ill or elderly patients often receive lower drug doses Overdose excessive dose, either intentionally or by accident Harmful effects We need to know Maximum dosage & Correct route!!!! E.g. Ingestion of a drug intended for external use Iatrogenic 醫源性 effects / disease caused unintentionally無意 by medical or drug therapy Negligence 疏忽 e.g. Aspirin cause GI irritation + bleeding, propranolol-induced bronchoconstriction (asthma), methicillin-induced nephritis, gentamicin-induced deafness, hepatic toxicity, renal damage, malformations of the fetus…… Drug Allergy ◼ hypersensitivity ◼ Abnormal response resulting from immunologic reaction to a drug ◼ When first exposed to a foreign substance (antigen), the body may react by producing antibodies, developing symptoms of mild allergic reaction or severe anaphylactic reaction ◼ Symptoms can occur anytime from a few minutes to 2 weeks after the administration of the drug 除咗問有冇allergy history之外, 要記住 問埋related signs and symptoms! How Drug Allergy present?? Mild reactions o Skin rash/ Urticaria Severe Reactions anaphylactic reaction o Itching/ Pruritus o Angioedema (increased permeability >>> life threatening/ fatal of blood capillaries) o Wheezing (on inhalation & o Diarrhea (irritation of mucosa of exhalation) and dyspnea large intestine) (accumulated fluids & o Vomiting (stimulation of related swelling of respiratory centers in brain) tissue) o Rhinitis (excessive nasal watery o Acute shortness of breath discharge) (SOB) o Lacrimal tearing o Acute hypotension Swelling in mouth & tongue o Tachycardia o (subjective feelings) What Nurses MUST DO?? 1) Check against with existing allergy status 2) Appropriate monitoring on drug effect on patient 3) Evaluate drug effect & side effect on patient 4) Early identification on potential allergy status 5) Relevant patient education on his/her drug profile Drug Effects – adverse reactions Idiosyncratic effect 異質效應 / responses Some sensitivity-related adverse reactions don’t result from pharmacologic properties of a drug or from an allergy but are specific to the individual patient It is unexpected under response / over response / completely different effect (other than normal response) of a drug to a particular patient It causes unpredictable and unexplainable symptoms in a particular client. Some idiosyncratic responses have a genetic cause e.g. Stevens-Johnson syndrome (SJS)史蒂芬強森症候群 Drug Effects - dependence Physiological 生理性 dependence 依赖 is due to biochemical changes in body tissues, especially the nervous system. These tissues come to require the substance for normal functioning. A dependent person who stops using the drug experiences withdrawal戒 斷 symptoms. Drug Effects - dependence Psychological 心理 dependence 依賴 is emotional reliance on a drug to maintain a sense of well-being, accompanied by feelings of need or cravings for that drug. Varying degrees of psychological dependence, ranging from mild desire 慾望 to craving 渴望 and compulsive 強迫性 use of the drug. Drug habituation成癮 denotes a mild form of psychological dependence The individual develops the habit of taking the substance and feels better after taking it. The habituated individual tends to continue the habit even though it may be injurious to health. Drug Effects – loss drug effect Drug tolerance 藥物耐受性 Decrease in response slowly Unusual low physiological response to a drug Need to increase the dosage to maintain a given therapeutic effect. Examples: Opiates, Barbiturates, and Ethyl Alcohol. Tachyphylaxis 快速耐受 / De-sensitization 脫敏 Decrease in drug effect quickly Drug resistance 耐藥性 Antibiotics loss drug effect Drug Interactions Drug Interactions 藥物相互作用 Drug interactions can occur between drugs or between drugs and foods. They can interfere with each other. The more drugs a patient receives, the greater the chances that a drug interaction will occur. Drug Interactions occur when the administration of one drug before, at the same time as, or after another drug alters the effect of one or both drugs. It may be beneficial or harmful. https://www.youtube.com/watch?v=aDsW8tx1KsY&t=37s Drugs-Food Interactions Food can also alter the rate and amount of drug absorbed from the GI tract, affecting bio-availability (amount of a drug dose that’s made available to the systemic circulation) E.g. Milk interferes with absorption of tetracycline 四環素 antibiotics.  Drug Interactions – Grapefruit Juice o Grapefruit Juice contains a class of organic compounds called furanocoumarins inhibits hepatic enzyme CYP3A4 that can reduce the metabolism of drugs and increase the risk of developing side effects. o Examples include - ✓ red yeast rice poducts r ✓ estrogen containing oral contraceptives ✓ antimalarial drugs (e.g. quinine) ✓ cholesterol-lowering statins (e.g. atorvastatin, simvastatin) ✓ blood-pressure lowering drugs - calcium-channel blocker (e.g. amlodipine, nifedipine) ✓ antidepressant (e.g. amitriptyline, clomipramine) https://www.youtube.com/watch?v=aj8KKItAp-I How to Prevent Drug Interactions? 1) Appropiate montioring ! 2) Early identification ! 3) Relevant patient education !  “How do you travel to your destination?” “How long it takes?” “What happens during the journey?” Pharmaco- kinetics ?? Pharmaco- dynamics “At your destination, what will you do?”  Pharmacokinetic Absorption – Distribution – Metabolism – Excretion (ADME) to an easier eliminated form Distributed drug to the drug target cell / organ to take effect Why Absorption, Distribution, Metabolism And Excretion (ADME) Is Important?? Time is required for absorption, distribution, metabolism and excretion (ADME) to take place the time course for ADME may differ due to the drug type, the health status of the individual and other factors therefore, understanding such time course would aid designing the drug dose and administration frequency ADME- Absorption Drug Absorption 1. Process by which a drug passes into the bloodstream 2. Unless given IV/intraarterial, a drug must cross several semipermeable cell membranes of GI and blood vessels before it reaches the systemic circulation. 3. Cell membranes are composed of Drugs may cross cell membranes by: lipids and proteins determines ⚫ Passive diffusion ⚫ Facilitated passive diffusion membrane permeability characteristics ⚫ Active transport ⚫ Endocytosis https://www.youtube.com/watch?v=a0-8A0zRzi4&t=188s Pharmacokinetics: Drug absorption and distribution Drug Formulation & Route affecting the absorption  Types of Drug Preparations Types Descriptions Aerosol A liquid, powder, or foam deposited in a thin layer on the skin by air pressure Aqueous solution One or more drugs dissolved in water Aqueous One or more drugs finely divided in a liquid such as water suspension Caplet A solid form, shaped like a capsule, coated and easily swallowed Capsule A gelatinous container to hold a drug in powder, liquid, or oil form Cream A nongreasy, semisolid preparation used on the skin Elixir A sweetened and aromatic solution of alcohol used as a vehicle for medicinal agents Extract A concentrated form of a drug made from vegetables or animals Gel or jelly A clear or translucent semisolid that liquefies when applied to the skin Liniment A medication mixed with alcohol, oil, or soapy emollient and applied to the skin Lotion A medication in a liquid suspension applied to the skin. Lozenge (troche) A flat, round, or oval preparation that dissolves and releases a drug when held in the mouth  Types of Drug Preparations Types Descriptions Ointment A semisolid preparation of one or more drugs used for application to the skin and mucous membrane Paste A preparation like an ointment, but thicker and stiff, that penetrates the skin less than an ointment Pill One or more drugs mixed with a cohesive material, in oval, round, or flattened shapes Powder A finely ground drug or drugs; some are used internally, others externally Suppository One or several drugs mixed with a firm base such as gelatin and shaped for insertion into the body (e.g., the rectum); the base dissolves gradually at body temperature, releasing the drug Syrup An aqueous solution of sugar often used to disguise unpleasant-tasting drugs Tablet A powdered drug compressed into a hard small disk; some are readily broken along a scored line; others are enteric coated to prevent them from dissolving in the stomach Tincture An alcoholic or water-and-alcohol solution prepared from drugs derived from plants Transdermal A semipermeable membrane shaped in the form of a disk or patch that contains a drug patch to be absorbed through the skin over a long period of time Drug Absorption ORAL (PO) - limitation Rate of absorption of a drug in the stomach is variable. 1. Food can delay the dissolution and absorption of some drugs combine with molecules of certain drugs, changing their molecular structure and subsequently inhibiting or preventing their absorption. 2. Acid medium in the stomach vary according to time of day, foods ingested, use of antacid medications, and patient’s age 3. Some drugs do not dissolve or have limited ability to dissolve in the GI fluids, decreasing their absorption into the bloodstream. 4. The first-pass effect occurs when oral drugs first pass through the liver and partially metabolized prior to reaching the target organ requires higher oral doses to achieve the appropriate effect Drug Absorption Intravenous (IV) route of choice for rapid action drug enters directly into the bloodstream/ vascular system without absorbed Intramuscular (IM) next most rapid route due to the highly vascular nature of muscle tissue Alert for those with high bleeding risk Subcutaneous route (SC) has a poorer blood supply than muscle tissue absorption is slower Rectal absorption tends to be unpredictable normally used when other routes are unavailable or when the intended drug action is localized to the rectum or sigmoid colon ADME- Distribution Drug Distribution ◼ Transportation of drug from its site of absorption to site of action ◼ Determining factors included: (1) Blood Flow - liver, kidneys and brain (most vascular organs), exposed to large amount of drug - lower blood supply, i.e. skin and muscles, receive the drug later (2) Solubility of a drug (Chemical & physical properties) - ability of a drug to cross cell membrane (phospholipids) depends on whether the drug is water or lipid (fat) soluble. - fat-soluble drugs will accumulate in fatty tissue, whereas other drugs may bind with plasma proteins ADME- Metabolism Drug Metabolism Bio-Transformation生物轉化: drugs would be chemically altered by the body Most drugs must pass through the liver (primary site for drug metabolism) via a specific group of cytochrome CYP-450 enzymes Liver enzymes convert prodrugs (administered in an inactive form) to active metabolites or convert active drugs to inactive forms as they may be similar to or different from the original drug in therapeutic activity or toxicity Metabolites may be metabolized further instead of being excreted from the body The subsequent metabolites are then excreted. Excretion involves elimination of the drug from the body, for example, in the urine or bile. What Does CYP450 Do In Drug Metabolism? o CYP450 enzymes are responsible for oxidation (gaining of oxygen) and reduction (removal of oxygen) reactions o To turn lipid-solubledrugs to water-soluble drugs for excretion by kidneys o To convert certain drugs into pharmacologically active metabolites  Factors Affecting Drug Metabolism First Pass Effect First pass metabolism / pre-systemic elimination Medication absorbed from GI tract enters the hepatic portal system through the portal vein into the liver The liver metabolizes / destroys many drugs, reduces active drugs reaching the blood circulation system, reduce the bioavailability of drug reaching its site of action Some oral drugs first pass through the liver and are partially metabolized prior to reaching the target The extent to which a organ, which requires higher oral doses in order to patient may undergo the first-pass effect varys achieve the appropriate effect among patients Heavy First-pass Effect drug may require administration via a different route or formulation to bypass the first-pass effect Bioavailability(BA) 生物利用度 1. The fraction (or percentage) of the administered dose of drug that reaches the systemic circulation. 2. Level of absorption can affect speed and quantity of the drug at site of action. 3. The rate and extent 程度 of absorption of the drug is greatly affected by the nature and the route of administration of the drug 給藥途徑 4. If a tablet releases the drug quickly, blood levels may become too high, whereas slow release may result in low levels of absorption.  What Nurses can DO?? 1) Alert for Suitable Route of drug given 2) Monitoring on Liver Function Test ADME- Excretion Drug Excretion  refers to the removal of drug from the body  Generally, only hydrophilic 親水性的 are excreted effectively. Accordingly, drugs may be excreted as unchanged parent molecules if they are sufficiently hydrophilic  Lipophilic 親脂性 drugs must be bio-transformed to hydrophilic drugs metabolites to be excreted  Changes in excretion rates will affect the plasma concentration of drugs and their metabolites and thus play an important role in the design of drug regimens.  Renal excretion is quantitively the most important route of excretion for most drugs or drug metabolites ◼ The efficiency depends largely on kidney function. ◼ Kidneys excrete drugs and metabolites diminishes with age. ◼ Older people and Renal patients may require smaller doses because metabolites may accumulate in the body. Other form of Excretion Excreted via a number of routes, such as in bile, sweat, and breast milk.  The lungs are an excretion route by which volatile lipophilic substances (e.g. inhaled general anesthetics) can be excreted.  Some drugs can also be excreted through the lungs (e.g. general anesthetic agents 麻醉劑), exocrine (sweat, salivary, or mammary) glands, skin.  What Nurses can DO?? 1) Alert for Age & Medical background of patient when drug given 2) Monitoring on Renal Function Test Understanding Pharmacokinetics related Terms Drug Half Life  Drug Half-life 半衰期 = half the drug ◼ Drug Half-life 半衰期 is the time taken to eliminate one-half of the drug in the body. 藥物半衰期是消除體內一半藥物所需的時間 ◼ The symbol for half-life is T½. ◼ Factors that affect a drug’s half-life include its rate of absorption, metabolism, and excretion ◼ Knowing how long a drug remains in the body helps determine how frequently it should be administered  Drug Half Life Example: A drug’s half-life is 8 hours, then the amount of drug in the body: T1/2 Hours taken % Remaining 0 Initially 100% 1 After 8 hours 50% A drug that’s given only 2 After 16 hours 25% once is eliminated from the 3 After 24 hours 12.5% body almost completely 4 After 32 hours 6.25% after 5-6 half-lives. 5 After 40 hours 3.125% Repeated doses are required to maintain a constant drug level in the body. How To Determine T1/2 Of A Drug? Drug Half Life o Drugs with shorter half-life tend to act very quickly, but their effects wear off rapidly, meaning that they usually need to be taken several times a day to have the same effect. o Drugs with longer half-life may take longer to start working, but their effects persist for longer, and they may only need to be dosed once a day, once a week, once a month, or even less frequently.  How important of Half-life?? 1) Know the duration of action after a single dose given 2) Time required to reach a steady state 3) Dosing frequency Steady State occurs when the rate of drug availability in the body = elimination from the body depending on the drugs half life, in general, it takes four to five doses of a regularly scheduled drug to reach a steady state This is important because the steady state concentration of a drug is necessary for adequate symptom management  Loading Dose & Maintenance Dose Loading loading dose dose maintenance given at the onset of therapy doses with the aim of achieving the target concentration rapidly maintenance dose the rate of drug administration is adjusted such that the rate of Onset of action: input equals to rate of loss, and that refers to the time the target steady state plasma interval from when the concentration is maintained drug is administered to when its therapeutic effect begin.  “How do you travel to your destination?” “How long it takes?” Pharmaco- “What happens during the journey?” kinetics ?? Pharmaco- dynamics “At your destination, what will you do?” Basic Concepts Of Pharmacodynamics Receptor and non-receptor mechanisms Agonists and antagonists the effect of a drug on an organism Study of Mechanism of action (MOA), interaction of drug with its receptor受體 or primary sites  Receptor and non-receptor mechanisms Receptor ○ is the drug’s specific target ○ like “lock and key” ○ Protein molecules in the target cell or on its surface ○ drug binds to the receptor, it enhances增強 or inhibits抑制 normal cellular function ○ The binding is usually reversible可逆的 and the action of the drug terminated 終止 once the drug leaves the receptor 藥物離開受體  Receptor and non-receptor mechanisms Receptor ○ 2 types of receptors: internal receptors and cell-surface receptors ○ 3 Types Of Cell Surface Receptors Agonists (促效劑) & Antagonists (拮抗劑) Agonists - Natural agonists are hormones or neurotransmitters. Artificial agonists are drugs that are made to resemble natural agonists e.g., glucocorticoids. There are 3 types of agonist drugs:  Agonists (促效劑) & Antagonists (拮抗劑) Antagonists are drugs that block a receptor and blocks/prevents the action of the endogenous transmitter e.g., beta-blockers. There are 3 types of antagonist drugs Dosage Calculation Let’s Play!  1 lb = ? kg  50 lb = ? kg Unit Conversion 單位互換  30 lb = ? Kg Same Unit before calculation  1 g = ? mg  1 mg = ? mcg 同聲同氣  1 L = ? ml  1 hr = ? mins Do not use μg for micrograms !!!  1 milliliter = ? ml Do not use cc for milliliters !!!  Approximate Household Measures Metric System 1 teaspoon = ~5 ml Weights 1 hour = 60 min 1 kilogram (kg) = 2.2 pounds 1 kilogram (kg) = 1000 grams (g) 1 gram (g) = 1000 milligrams (mg) 1 milligram (mg) = 1000 micrograms (mcg) 100mg/5ml 20mg/mL Volumes 1 liter (L) = 1000 milliliters (mL) 1 oz = 30 mL International Unit (IU） Dilution/ Split of Drugs (ORAL Tablets or Capsules)  Tablets that are scored刻痕 may be divided into two halves 分成兩半  A tablet must be scored by the manufacturer to be divided properly Liquid medication (Parenteral Medications)  Rounding depends on the amount appropriately  1mL毫升 Tuberculin (TB) syringe ~ has markings for hundredths of a milliliter (mL) 百分之一毫升, commonly used in pediatrics 兒科  3mL syringe ~ has calibrations where each line indicates one-tenth of a milliliter (mL) 十分之一毫升  10mL syringe ~ indicates a 0.2mL increment 增量 SMART Nursing Tips i) Capsule cannot be divided ii) some drugs cannot be chewed or cut/ or need to “swallow in whole” iii) proper choosing on appropriate devices/ syringe (e.g. cutter, measuring cups, teaspoon etc) to administer an accurate dosage iv) Proper handling on special case: a. “DRUG A” resulting in 1.9 tablets in calculation, gives 2 tablets or capsules because it is unrealistic b. Rounding dosage numbers E.g. Quantities greater than 1 are rounded to the nearest tenth 1.67 = 1.7 1.63 = 1.6 Quantities less than 1 are rounded to the nearest hundredth 0.823 = 0.82 0.825 = 0.83 Method 1 Universal Formula 單位要相同 !!! o (D) Amount Desired is the dose prescribed o (H) Amount on Hand or the amount you “have” is the available dose or concentration o (Q) Quantity is the form and amount in which the drug is supplied (i.e. tablet, capsule, liquid). o Desired Amount (D) & Amount on Hand (H) Must always be in the same units (D) Amount Desired Dose = X (Q) Quantity (H) Amount on Hand  (D) Amount Desired 5mg Step 1 : determine your givens (H)Amount on Hand 100mg p e r tablet (Q) Quantity 1 Step 2: Plug-in what you know into the formula and simplify = 0.5 tablet Example Question: There is a drug order for 50 mg of secobarbital (elixir). The stock bottle contains 22 mg of secobarbital in 5 mls of solution. How many milliliters should the patient receive? (D) Amount Desired 50 mg Step 1 : determine your (H) Amount on Hand 22mg /5mL givens (Q) Quantity 1 mL Step 2: Plug-in what you know into the formula and simplify = 11.363636… (11.4 ml) Method 2 Ratio and Proportion: Numerator 分子 Numerator/ Denominator Denominator 分母 H (Amount on Hand) Amount Desired (D) = Q (Quality or form in which unknown amount (Y) to administer drug comes (tablet/liquid)  Once the equation is set up, cross multiply the opposite side (numerator x denominator) 交叉相乘 單位要相同 !!! Example 單位要相同 !!! H (Amount on Hand) Amount Desired (D) Q (Quality or form in which = unknown amount (Y) to administer drug comes (tablet/liquid) Doctor prescribed 8mg bisolvon for patient. Existing bisolvon syrup is 0.004g/5ml. How many ml you would give to patient? 0.004 g = 4 mg 4 mg 8 mg 5 ml = (Y) 4Y = 40 Y = 10 You should give 10ml! Example 單位要相同 !!! H (Amount on Hand) Amount Desired (D) = Q (Quality or form in which unknown amount (Y) to administer drug comes (tablet/liquid) You administered 40 mg of furosemide (Lasix) PO. You had only Lasix 20 mg per ml. How many ml(s) should you give? 20 mg 40 mg = 1 ml (Y) 20Y = 40 Y=2 You should give 2 ml! Dosage Calculation (Advanced) – Include Body Weight Example A patient weighing 170 lbs must be given amikacin 15 mg/kg/day Intravenous (IV). The drug stock is 250 mg/ml (vial). The nurse will give ______ / day through IV. Remember to deal with weight !! HINTS 1kg=2.2lbs Patient kg = (170 lb)/(2.2 lb) = 77.3kg Amikacin 15 mg/kg/day Amikacin for the patient per day = 15mg/kg x 77.3kg/day = 1159.5 mg/day Amikacin Drug stock 250 mg/ml vial = 1159.5 mg/day 250mg/ml = 4.6ml/day Dosage Calculation – Include Body Weight Remember to deal with weight !! Example A patient weighing 198 Ibs must be given “Drug A” 4 mcg/kg/min via IV infusion Standard solution setting “500 mg in 250 mL NS” via infusion pump What is the infusion pump setting? How do you deal with this order?? *** Remember that Infusion pumps deliver ml/hr ***  1mg = 1000mcg “Drug A”: 4 mcg/kg/min HINTS Patient kg = (198 lb)/(2.2 lb) = 90kg “Drug A” for the patient 4mcg = kg / min x 90 kg = 360 mcg/min = 0.36 mg/min = 21.6 mg/hr Standard solution of 500 mg in 250 mL NS 500mg = 250ml Infusion pump setting 21.6 mg = 500mg X 250 𝑚𝑙 = 10.8 ml/hr What Nurses MUST DO?? 1) Correct & Appropriate Calculation method 2) Be familiar with Same Unit 3) Double check or Ask if in doubt 4) Be serious in calculation Why important?? 1) Prevent medication error 2) Ensure patients’ safety  Thanks! 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