How To Calculate Drop Rate per Minute for an IV Without Using a Pump

In this high tech world, a lot of nurses, especially the youngest, do not know how to count drops per minute for intravenous fluid and or medication. It used to be fairly simple; the physician orders 1000 ml over 8 hours, easy, 125 ml per hour. Get a piece of tape, a magic marker and run the tape down the edge of the bag marking 125 ml off along the way. Go back every 15 minutes for the first hour just to be sure everything is OK. Roll the blue roller on the tubing up or down....depends in the amount of fluid going into the patient. No biggee, we all did it this way.

Righto! Moving right along and aren't you glad we did! Amazing anyone survived students and nurses in the '70s....HEY!!!

 I Heard That! Watch It Bud!

You know we no longer sharpen our needles on our tongues/anymore/but I know who still does!!!      :)       Shall I call her?

Nurse Kracket! Paging Nurse Kracket!

Enough of this levity! When and why would you need to know how to calculate drops per minute for an intravenous medication? In most major hospitals all we see are these pump-thingies with buttons and lights and alarms.

When and why would you need to know how to calculate drops per minute for an intravenous medication?

When you are a home health nurse you learn a lot of different skills than you do in a hospital. Yet, even for a home health patient on an intravenous fluid and or medication do you really need to know all this stuff? After all, the home health agency contracts out to an infusion company, they send out to the patients’ house everything you could possibly need! They leave a folder in the home, just like a home health nurse and the home health nurse can call and get assistance with anything that comes up.  Besides all that, don’t infusion companies also have those fantastic IV pumps like the CaddPlus? It’s LED readout walks you through every step. Even getting the battery in and out is easier than it used to be!  At any rate, even if the patient has to get their medication without a pump the infusion company sends out a dial flow and that’s really all you need. Just attach it to the end of the line, prime it, attach to the infusion cap and there you go, it will count the drops for you! Oh really? Did you read the fine print in the dial a flow instructions about how far above the patient’s heart it’s supposed to go? Also did you know you can actually crack the dial a flow so hard it pours all the fluid in without stopping? And oh do NOT forget that with a PICC line they are notorious at any rate for slowing down especially if the patient is not still.

So OK, I get it, some medications cannot be given on a pump a pump and you cannot place all your faith in every high tech gadget that comes along. They are tools, not absolutes. SO fine, I have a question, I’m stuck, what do I do?

Personally, this nurse’s motto has always been

 “If anything comes up about a patient on an IV infusion that you cannot handle, just call Duck!”

So there you have it, in a nutshell:

Top notch info on infusion companies as a home health nurses ally plus what this author, in her considered opinion , believes is the number one best infusion nurse EVER!

 Carol Duck! Go Duck!

NAME ONE IV MEDICATION THAT CANNOT GO ON A PUMP IN A HOME HEALTH SETTING

Now back to the case at hand. There’s just one tiny thing. A few of the medications, mainly antibiotics, cannot go on a pump at all. One example is Vancomycin. This antibiotic has been used as a front line defense for resistant staph infections. A lot of the time it is administered through a central line, like a groshong, or through a peripherally central line like a PICC. The reason for this is Vancomycin is extremely caustic to tissues. Usually, the IV site itself will not last over 24 hours at any rate. Plus, if you have to receive this antibiotic, the course can take several weeks to even months. A good reference site for Vancomycin is on Medline Plus.

Home health nurses must be able to recognize signs of complications to the IV site, the IV medication as well as complications related to the disease process for why the medication was ordered in the first place. If you are receiving Vancomycin, at the least you will require weekly lab work for Vancomycin peak. Most of the time the physician will order weekly Vancomycin trough (taken before the IV starts) and the peak (taken 30 minutes to an hour after the IV ends).The home health nurse must change the IV site to the central line, PICC or groshong, weekly and as needed as well as know when and how to obtain lab work from the central line as well as know when and how to change the infusion cap on the end f the tubing of the central line. Oh and let’s add this tidbit; home health is chosen because the patient lives in a remote location and coming to an outpatient clinic at a hospital of a doctor’s office would be an undue hardship.

So, just for funsies let’s make a scenario….there you are, sick, on your farm or your ranch and you just got out of the hospital and here comes a home health nurse. What kind of home health nurse would YOU prefer?

Me too!!! Preferably ANCC certified to boot! Though, alas, that is no longer offered through ANCC. That’s for another Hub Page.

THAT ANSWERS WHEN BUT WHY DO YOU NEED TO KNOW HOW TO CALCULATE DROPS PER MINUTE?

Let’s stick with Vancomycin; it’s a good example to use. One of the things about this med is it MUST infuse in NO LESS THAN SIXTY MINUTES! If the amount of fluid in the IV bag is over 150 ml, then best practice would tell you to infuse it even longer.

Geez Nurse Kracket! What do want from me? I’m way out in the boonies, got tons of patients and lab work and wound care plus being on call and now you want me to spend even more time at this patient’s house? What would the worst case scenario be if you ran the antibiotic too quickly? If it is in a central line it isn’t going to infiltrate, if the patient stays still won’t that be OK? Hmmm… let’s look at that picture again. Where does the tip of both a groshong and a PICC line end up?

OH! Right atrium of the heart, eh? Talk about mainlining. And remember that side effect of red rash over body with the Vancomycin? Well, that’s called red man syndrome…not a pleasant thing. Although not necessarily due to Vancomycin infusing too quickly, try getting around the fact that if and when red man syndrome occurred on your watch you were also infusing the antibiotic faster than would be considered best practice! Quality review would …well, you as nurses know what QA would do. For you lay people rest assured QA is there to protect you as patients!

The number one reason for all nurse to know how to calculate drops per minute when you do not have an IV pump is?

YEA!!! Go to the head of the class!!

SAFETY.

ALWAYS AND FOREVER; FIRST, DO NO HARM.

We could branch out and add the Joint Commission Safety Rules here as Well but I see a few eyelids drooping…J

FINALLY!!! LET’SLEARN HOW TO CALCULATE DROPS PER MNUTE WITHOUT BRUISING OUR BRAINS!

This picks up now as if you are ready to perform and instruct your patient to perform this intravenous medication infusion. Remember! A home health nurses role is to assess, evaluate, perform and instruct their patient on all aspects of their care and treatment.

· Wash your hands. Instruct your patient to do so and how to do so at the same time. Why? Because more than likely, this patient will be doing a large portion of these IV infusions for themselves.

· Gather your equipment. Your equipment is in a bag or a plastic cooler type box with everything neatly labeled by the infusion company. Try to keep it that way!

· You already called your patient ahead of time and gave an estimated time of arrival. The patient has already taken the IV medication out of the refrigerator.

· Get one primary tubing set, one dial a flow, dead end cap (red or blue), two pre filled syringes of 0.9% NACL (sodium chloride) and one of of hep lock solution( just in case), paper tape measurer and alcohol swab

Now is the time to instruct your patient on how all the tubing hooks up together patients IV line with the sodium chloride it is time to attach the other end of the IV to the, how to scroll the roller down to cut off the flow, how to attach the dial a flow to the tubing and set the rate. Once everything is primed and ready and you have flushed the line with sodium chloride it is time to start this medication infusion. A dial a flow works on an hour timer. Say there is 100 ml of fluid in the bag and you have Vancomycin, what is the least amount of time it can be given? Of course, so set the dial a flow for the ml to be given in an hour; 100ml. But we already know that is not the safest wyt to go. You’d be amazed how FAST an hour goes when you are ALONE in the middle of nowhere with a patient and something goes wrong.

1. Take the medication bag and write down everything you see on the label and on the bag of solution itself. You need it to verify your patient, the drug, the route, the time…uhhhh…what’s that called? Ha just testing you! You will need all of this information and more not just to figure out drop rate but to document into your home health notes! Do NOT forget to write the lot number and expiration rate of the medication, the solution the medication is in and the saline you used to flush the line.

2. Multiply the amount of fluid in the bag to the drops per ml of the primary tubing set. What do you mean you threw it away?    OH YOU GUYS! Been around me too long!! It will probably be 15 drops per ml, but could be 10, 15, 30 or 60.  Read the packages!!

3. Let’s say you have a bag of Vancomycin with 250 ml of fluid x 15 drops per ml of the primary tubing set equals 3750

4. Divide that by the amount of time you want the medication to infuse. Is 250 too much? To me it is. So 3750 divided by 120 equals 31.

5. Your drop rate is 31 drops per minute.

6. Now for the dial a flow setting. What was that? Dial a flow doens’t go higher than 200 on the roller? Whereas that would be a problem if the amount of fluid in the IV bag were 500ml, in this case you are fine because as I said, the dial a flow works on an hour principle. Half of 250 equals 125 so set the scroll for that but then what?

7. ABSOLUTELY!!!

8. Count your drops per minute. The first time try and stand there with your watch and count a full minute but patients will distract you if the things you do take what they feel is inordinately long. So count for 15 seconds and multiply by 4, that’s good. Now, which roller can you use if it does NOT come ut closest to 31 drops per minute? The one on the primary set or the one on the dial a flow? Right. The one on the dial a flow. That must be why they call it a dial a FLOW! It controls the FLOW! OHHH!!!!

9. Real hard wasn’t it? All of that information just to give you a three step process for calculating dops per minute without a pump. Cool

 Now finally one more HUGE thank you to the homehealth nurse that taught m this quick ad easy formulae in the first place!

Thank you Kim Hamric! You Rock!