Learning objectives
Accreditation competencies
Key terminology
Pre-procedure considerations

We acknowledge that there may be variations in the technique presented.

You should perform this procedure under the supervision of an appropriately skilled supervisor until you are confident and competent enough to do it on your own.

Before using any medication or equipment in this procedure, please read the approved product information for instructions, contraindications, adverse effects, and warnings. Familiarize yourself with the equipment. The equipment or medication available to you may differ from what is used in this demonstration. You must inquire with a supervisor or instructor if there are variations or questions related to the equipment, medication, or procedures.

Review the physician's order. Confirm the name, the type of medication to be used, and the required dose.

The type and dose will differ depending on the patient's diagnosis.

Set up the tray with the required equipment for the procedure.

Attach a disposable mouthpiece to the peak flow meter. Set the indicator to the bottom of the scale to obtain accurate measurement of the patient's "expiratory effort" (see reference).

Peak flow meter

Place the nebulizer on a sturdy surface, and plug the device into a grounded outlet.

Remove the medication from storage, and perform the first check against the physician's written medication orders. Check the name and dose of the medication.

Inspect the medication, ensuring that it is free of crystals, lumps, and/or discoloration.

If necessary, calculate the correct dose needed for the patient, and confirm your calculation with another staff member.

Perform a second medication check, checking the medication label against the information provided on the physician's orders.

If required, draw up the prescribed dose, as indicated by the physician's orders.

Switch the machine on. Check if paper is loaded correctly and is sufficient for the test to be performed. Attach tubing to the machine and the mouthpiece, following the manufacturer's instructions.

Spirometer

Read through any information pertaining to the medication being administered. Check the information for the purpose of the medication, contraindications, side effects, and the appropriate dose for different age groups.

Check the equipment; ensure that you are familiar with the operation of the equipment being used.

Wash your hands before starting the procedure.

Washing hands

Always take standard precautions.

Greet the patient and introduce yourself.

Confirm patient details.

Conduct the third medication check against the physician's written orders.

Explain the purpose of the procedure to the patient.

Discuss the peak flow meter assessment, and explain that the procedure is used in the assessment of lung function.

Discuss the nebulizer treatment and explain its benefit.

Discuss spirometry and explain its use in the measurement of lung function. Discuss the main measurements of respiration, vital capacity, and forced expiratory volume, which are taken during spirometry.

Explain any possible side effects associated with the medication. Discuss the possible amplification of side effects observed in nebulizer treatment, due to increased dosage.

Address any concerns the patient or caregiver may have, and answer any questions raised by the patient.

Check whether the patient has followed the pre-procedure instructions, particularly for spirometry (eg, not consuming alcohol up to 4 hours before the procedure). If these instructions have not been followed, re-schedule the appointment.

Inquire about any known allergies.

Obtain consent to proceed.

Maintain patient privacy at all times.

Discuss and demonstrate correct positioning for the procedure. The patient should preferably be standing, so that the lungs can be fully expanded and accurate results can be obtained. Alternatively, if unable to stand, the patient may sit upright (high Fowler's position) for the procedure.

Any tight clothing, particularly belts, neckties, or brassieres, should be loosened, in order to reduce their restricting effects on respiration.

Patient positioning:
peak flow meter test

Explain the correct inspiration and expiration technique to the patient. Instruct the patient to breathe in as deeply as possible and to exhale as hard and as quickly as possible in one breath.

Instruct the patient on the correct placement of the mouthpiece beyond the teeth and how to seal the mouthpiece with the lips, to prevent any leakage of air. Inform the patient that they must not place their tongue in the mouthpiece, as this will lead to airflow obstruction and will ultimately affect the accuracy of the results.

Inserting
mouthpiece

Discuss how to hold the device: horizontally, with the opening of the meter and the pointer unobstructed by the fingers.
If necessary, demonstrate correct use of the meter to the patient and if appropriate allow the patient to practice the technique and provide feedback.

Allow the patient to rest before commencing the test.

Instruct the patient to inhale, breathing in as deeply as possible.

Ask the patient to insert the mouthpiece into their mouth, forming a seal with their lips, and to avoid placing their tongue in the mouthpiece.

Tell the patient to exhale quickly and forcefully in one single breath. The indicator will move up the meter as the patient exhales.

Marker position
following exhalation

Record the measurement, and then reset the marker to the bottom of the scale.

Repeat the process twice more. Ask the patient to inhale deeply and exhale quickly and forcefully. Record the measurements on the patient's chart and clearly mention the date and time of the readings.

Perform a peak flow meter test. Performing the test before and after administration of nebulizer treatment provides a measurement of treatment efficacy.

Record the patient's vital signs, including:

• pulse
• respiration
• breath sounds
• pulse oximetry

Measuring
vital signs

Remove the lid from the nebulizer medication cup. Place the medication and  diluent (eg, saline) in the cup and attach the lid.

Medication in
nebulizer cup

Select and attach the mouthpiece or, where appropriate, the face mask to the nebulizer cup.

Follow the manufacturer's instructions for attaching tubing to the nebulizer outlet, air compressor or   oxygen source, and for attaching the nebulizer cup to the tubing.

Nebulizer

Set the flow, if required, according to the physician's order; generally, this is at a level of 6 to 8 liters per minute (see reference).

Instruct the patient to sit upright on an examination bed or a chair, to allow for full expansion of the lungs.

Patient positioning
- nebulizer treatment

Turn the nebulizer on, so that a fine mist appears from the tube opposite the mouthpiece or face mask.

Instruct the patient to place the mouthpiece between their teeth, with their lips forming a seal around the mouthpiece.

Nebulizer
mouthpiece in place

If a face mask is being used, place the mask firmly over the patient's mouth and nose.

Nebulizer face
mask in place

Ask the patient to take slow, deep breaths (slightly above normal) through the mouth, and to hold their breath for 2 to 3 seconds before exhaling.

Ask the patient to use this technique until the medication is completely administered. This should take approximately 10 to 15 minutes. Once the medication has been completely nebulized, there will no longer be any mist exiting the tube.

During the procedure, take the patient's pulse rate. When the mist diminishes, tap the medication cup, to ensure complete nebulization of the medication.

If the patient experiences any dizziness or tremors, allow the patient to rest for 5 minutes before continuing at a slower breathing rate. Unless the physician orders otherwise, continue with the treatment.

Switch the nebulizer off once the treatment is complete.

If required, ask the patient to take a deep breath and cough into a tissue to clear any lung secretions, and discard the tissue in the biohazard waste bag.

Inserting
mouthpiece

Re-check the patient's peak flow and vital signs following the nebulization, and compare the results with those gathered before the procedure. This will provide some initial indication of treatment efficacy.

Assess the patient's vital signs, including:

• blood pressure
• temperature
• respiration
• pulse

In addition, measure and record the patient's height and weight. Measurement of height is important, as information around expected results is partially calculated on the basis of height. Weight is not necessarily a determining factor in calculating expected results, but may affect lung function (see reference).

Instruct the patient either to stand, or to sit upright, with their feet flat on the floor and their legs uncrossed. This position is necessary for ensuring maximum expansion of the lungs and facilitating accurate measurement.

Patient positioning:
spirometry

Ask the patient to remove ill-fitting dentures.

Instruct the patient to tilt their head back slightly, so the chin is elevated and the neck is extended.

If the patient is wearing any restrictive clothing, such as a belt or neck-tie, ask them to loosen or remove it, to facilitate lung expansion.

Use a disposable nose clip during the procedure, to prevent the escape of air through the nose.

Use simple, instructional language to explain the procedure to the patient.

Tell the patient how to position the mouthpiece, ensuring that it is straight and between the teeth. Instruct the patient to close their lips around the mouthpiece to form a seal, to prevent air escaping.

Explain the inhalation and exhalation technique needed for the procedure. Instruct the patient to take as deep a breath as possible, and then to exhale fast and forcefully in one long complete breath.

Throughout the demonstration, and continuing into the procedure, use an assertive coaching technique. Use strategies such as raising the volume of your voice and presenting the instructions using an urgent tone of voice. Where appropriate, demonstrate the process to the patient.

Give the patient an opportunity to practice the procedure themselves. Provide constructive feedback, indicating what they are currently doing well and where they could improve.

Allow the patient to rest before performing the test.

Position the disposable nose clip correctly.

Instruct the patient to inhale, using the technique demonstrated beforehand.

Ask the patient to place the mouthpiece in their mouth; ensure that it is placed between the teeth and that the mouthpiece is completely sealed by the patient's lips.

Using an assertive coaching style, tell the patient to exhale forcefully and quickly. Monitor the patient for any adverse reactions, such as vertigo or dyspnea, during exhalation.

Continue to give constructive feedback to the patient on technique. Ensure that you provide constructive feedback on how they could improve.

Three acceptable cycles of the procedure should be completed. An acceptable cycle is one in which the patient does not cough or stop blowing during exhalation, and their inhalation and exhalation is consistent.

For every cycle completed, obtain a spirogram. To obtain an accurate assessment of pulmonary function, use the two best spirograms.

Spirogram

Assess the patient for comfort and safety. If a steroid has been administered during nebulizer treatment, allow the patient to rinse their mouth.

Conduct patient education. Ensure that the following is discussed:

• Equipment instructions - include details on how to use and care for the equipment.
• Test instructions - work through the necessary procedures, explaining how to conduct each one.
• Medication information - Include information on medication dose/levels, any possible side effects, and what to do if the patient experiences side effects.

Address any questions the patient may have at the conclusion of the procedure, and inform the patient of any necessary follow-up.

If the physician approves the results, escort the patient from the room.

Perform the fourth medication check, comparing the information against the physician's orders.

Remove and discard the used materials into the biohazard waste bag or, if appropriate, into the biohazard sharps container.

Discarding
used materials

If you have not already done so, switch off the equipment used in the procedure(s).

Clean and disinfect the equipment and work area.

Remove your gloves and discard them in the biohazard waste bag. Wash your hands.

Complete the patient's medical record. Record the:

• patient's vital signs
• peak flow test results on the appropriate graph, including the highest reading, as well as the date and time of the reading
• patient's reaction to nebulization treatment
• spirometry results

Complete patient
records

Complete the medication record. Record the name and dose of the medication administered, and the date and time of administration.

Complete
medication record

References

NetDoctor. Asthma: how to use your peak flow meter. Available at: http://www.netdoctor.co.uk/diseases/facts/asthmapeakflowmeter.htm
Accessed September 14, 2010. 

Madama VC. Pulmonary Function Testing and Cardiopulmonary Stress Testing. Available at: http://books.google.co.nz/books?id=WDSVGYUc7FIC&pg=PA3&lpg=PA3&dq=%22volume+displacement%22+spirometer&source=bl&ots=TKSpwFAyMH&sig=Bf1ZUm7X87qvoGXXFM88PVKKh4s&hl=en&ei=AbeOTIS8Eor2swP2to3FBA&sa=X&oi=book_result&ct=result&resnum=10&ved=0CEUQ6AEwCQ#v=onepage&q=%22volume%20displacement%22%20spirometer&f=false
Accessed September 14, 2010. 

Young A, Proctor D. Kinn's The Medical Assistant: An Applied Learning Approach. 10^th ed. St. Louis, MO: Saunders Elsevier; 2007. 

Scribd.com. Nebulizer Therapy. Available at: http://www.scribd.com/doc/13071341/Nebulizer-Therapy
Accessed September 16, 2010.

NDD Technologies Inc. 'BOLD Spirometry Protocol', Available at: http://webcache.googleusercontent.com/search?q=cache:nfrSDuC9Gw4J:www.ndd.ch/UserData/Download_00096_00.doc+why+measure+height+and+weight+before+spirometry%3F&cd=2&hl=en&ct=clnk&gl=nz
Accessed October 7, 2010

Other resources

Asthma Helpline. Spirometer. Available at: http://www.asthmahelpline.com/spirometer.htm
Accessed September 13, 2010.

Cooper K, Mitchell P. Procedure for the assessment of lung function with spirometry. Available at: http://www.nursingtimes.net/nursing-practice-clinical-research/procedure-for-the-assessment-of-lung-function-with-spirometry/205400.article
Accessed September 10, 2010.

eHow Incorporated. Nebulizer Treatment Procedure. Available at: http://www.ehow.com/how-does_5031555_nebulizer-treatment-procedure.html
Accessed September 13, 2010.

Houghton Mifflin Company. Peak flow measurement. Available at: http://www.answers.com/topic/peak-flow-measurement
Accessed September 9, 2010.

U.S. National Library of Medicine. Peak expiratory flow rate. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003443.htm
Accessed September 9, 2010.