1. NUR 232 : SKILL 21-7 USING SMALL-VOLUME NEBULIZERS

2. INTRODUCTION
Nebulization is a process of adding medications or moisture to inspired air by making particles of various sizes with air.
Adding moisture to the respiratory system through nebulization improves clearance of pulmonary secretions.
Medications such as bronchodilators, mucolytics, and corticosteroids are often administered by nebulizations.

3. INTRODUCTION – CONT’D
Small-volume nebulizers convert a drug solution into a mist that is then inhaled by a patient into their tracheobronchial tree.
The droplets in the mist are much finer than those created by metered-dose inhalers (MDIs), or dry powder inhaler (DPIs).
A face mask or a mouthpiece held between the teeth delivers a nebulized mist.
A nebulized medication is designed to create a local effect, but it can be absorbed into the bloodstream through the alveoli. As a result, systemic efforts from the medication may occur.

4. ASSESSMENT
1. Check accuracy and completeness of each medication administration record (MAR) with health care provider’s medication order. Check patient’s name, drug name and dosage, route and time for administration. Clarify incomplete or unclear orders with health care provider before administration.
2. Review pertinent information related to medication, including action, purpose, normal dose and route, side effects, time of onset and peak action, and nursing implications.
3. Assess patient’s medical history, history of allergies, medication and diet history.

5. ASSESSMENT – CONT’D
4. Assess patient’s grasp and ability to assemble, hold, and manipulate nebulizer equipment.
5. Assess pulse, respirations, breath sounds, pulse oximetry, and peak flow measurement (if ordered) before beginning treatment.
6. Assess patient’s knowledge of medication and readiness to learn (e.g., patient asks questions about medication, requests education in use of nebulizer, is mentally alert, participates in own care.)

6. PLANNING 1. Expected outcomes following completion of procedure:
Patient’s breathing pattern is effective.
Patient’s oxygen saturation level is adequate.
Patient describes side effects of medication and criteria for calling health care provider.
Patient demonstrates self-administration of nebulized dose of medication correctly.
2. Explain procedure to patient. Be specific if patient wishes to self-administer drug.

7. IMPLEMENTATION
1. Prepare medication for inhalation. Check label of medication against MAR 2 times (see Skill 22-1). Preparation usually involves taking medication vial out of storage and taking to patient room. Check expiration date on container.
2. Take medication (s) to patient at correct time (see agency policy). Medications that require exact timing include stat, first-time or loading doses, and one time doses. Give time- critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive agents) at exact time ordered (no later than 30 minutes before or after scheduled dose). Give non- time critical scheduled medications within a range of 1 or 2 hours of scheduled dose. During administration, apply six rights of medication administration.

8. IMPLEMENTATION – CONT’D
3. Perform hand hygiene and arrange equipment needed.
4. Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers in MAR / medical record with information on patient’s identification bracelet and / or ask patient to state name.
5. At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if he or she has allergies.
6. Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions about the drugs. Explain how to assemble nebulizer and proper use.

9. IMPLEMENTATION – CONT’D
7. Assemble nebulizer equipment per manufacturer directions.
8. Add prescribed medication by pouring medicine into nebulizer caps (Option, you may use a medicine dropper or syringe to instill medication).
9. Attach top to the nebulizer cup and be sure it is secure. Then connect cup to mouthpiece or face mask.
10. Connect tubing to both aerosol compressor and nebulizer cup.

10. IMPLEMENTATION – CONT’D
11. Have patient hold mouthpiece between lips with gentle pressure, but be sure lips are sealed.
Prevents loss of medication.
A. If patient is an infant, child, or fatigued adult or unable to follow instructions, use face mask.
B. Use special adapters for patients with tracheostomy.
12. Turn on small volume nebulizer machine and ensure that a sufficient mist begins to flow.

11. IMPLEMENTATION – CONT’D
13. Have patient take deep breath, slowly, to a volume slightly greater than normal. Encourage brief, end-inspiratory pause for about 2 to 3 seconds, then have patient exhale passively.
A. If patient is dyspneic, encourage him or her to hold every fourth or fifth breath for 5 to 10 seconds.
B. Remind patient to repeat breathing pattern until drug is completely nebulized. This usually takes about 10 minutes.
1. Some health care providers set time limit as length of treatment rather than waiting for medication to completely nebulize.
C. Tap nebulizer cup occasionally during and toward end of treatment.
D. monitor patient’s pulse during procedure, especially if beta-adrenergic bronchodilators are used.

12. IMPLEMENTATION – CONT’D
14. When medication is completely nebulized, rung off machine. Rinse nebulizer cup per agency policy. Dry completely and store tubing assembly per agency policy.
15. If steroids are nebulized, instruct patient to rinse mouth and gargle with warm water after nebulizer treatment
Removes medication residue from oral cavity and helps to prevent oral candidiasis, a possible adverse effect of inhaled steroid therapy.
16. After nebulizer treatment is complete, have patient take several deep breaths and cough to expectorate mucus.
Nebulized medication is often ordered to open airways and promote expectoration of mucus.
17. Help patient to comfortable position and perform hand hygiene.

13. EVALUATION
1. Assess patient’s respirations, breath sounds, cough effort, sputum production, pulse oximetry, and peak flow measures if ordered.
Determines status of breathing pattern and adequacy of ventilation / gas exchange. Allows comparison with baseline data and evaluation of effectiveness of procedure.
2. Have patient explain and demonstrate steps in use of nebulizer.
Return demonstration provides feedback for measuring patient’s learning.
3. Ask patient to explain drug schedule.
Improves likelihood of adherence to therapy.
4. Ask patient to describe side effects of medication and criteria for calling health care provider.
Allows patient to recognize signs of overuse and need to seek medical support when drugs are ineffective.

14. UNEXPECTED OUTCOMES
1. Patient’s breathing patter is ineffective; respirations are rapid and shallow; breath sounds indicate wheezing.
Reassess type of medication and / or delivery method.
Notify health care provider.
2. Patient experiences paroxysms of coughing. Aerosolized particles can irritate posterior pharynx.
Reassess type of medication and / or deliver method.

15. UNEXPECTED OUTCOMES – CONT’D
3. Patient experiences cardiac dysrhythmias (light-headedness, syncope), especially if receiving beta-adrenergics.
Withhold all further doses of medication. Assess vital signs.
Notify health care provider for reassessment of type of medication and delivery method.
4. Patient is unable to self-administer medication properly.
Explore alternative delivery routes or devices.
5. Patient is unable to explain technique and risks of drug therapy.
Further teaching may be required.
Include family caregivers when possible.

16. RECORDING AND REPORTING
Record drug, dose and strength, route, length of treatment, and time administered on MAR immediately after administration, not before. Include initials or signature. Record patient teaching and validation of understanding in nurses’ notes and EHR.
Record patient’s response to treatment in nurses’ notes and EHR.
Report adverse effects / patient response and / or withheld drugs to nurse in charge or health care provider.

17. SPECIAL TEACHING GERONTOLOGIC:
Teach patient not to store medication in nebulizer for later use.
Advise patients taking long-acting beta-agonists about possible adverse effects, including nervousness, restlessness, tremor, headache, nausea, rapid or pounding heart, and dizziness.
Teach patients to use small, handheld peak flow-meters to monitor response to therapy when inhaled drugs are prescribed.
GERONTOLOGIC:
Older adults with a weak grasp, hand tremors, or coordination problems may not be able to manipulate or hold a nebulizer.

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