SESSION 1: ‘AEROSOL DELIVERY DEVICES The inhalation route is a fast and effective way of delivering medication locally to the lungs and also for the systemic administration of certain agents. Inhalation drug therapy is used extensively to treat respiratory conditions. A wide selection of inhaler devices is available, each with specific design characteristics. Therefore, choosing the most appropriate device to meet an individual patient's needs is an important clinical consideration. There are 3 major benefits of delivering medication via the inhaled route: rapid onset of action, high local concentration by delivery directly to the airways (and hence high therapeutic ratio and increased selectivity), and needle-free systemic delivery of drugs with poor oral bioavailability. ‘A. NEBULIZERS "Nebulization is a common and alternative method of drug delivery to the lungs. Iti largely used in clinical settings for the treatment of acute respiratory ailments as well as for the long-term treatment of obstructive airway diseases. It is also a the process of medication administration via inhalation. It utilizes a nebulizer which transports medications to the lungs by means of mist inhalation. Nebulization therapy is used to deliver medications along the respiratory tract and is indicated to various respiratory problems and diseases such as: Bronchospasms, Chest tightness, Excessive and thick mucus secretions, Respiratory congestions, Pneumonia, Atelectasis, and Asthma. "Nebulization is a process by which medications are added to inspired air and converted into a mist that is then inhaled by the patient into their respiratory system (Lilley et al., 2011; Perry et al., 2014.) The air droplets are finer than those created by metered dose inhalers, and delivery of the nebulized medication is by face mask or a mouthpiece held between the patient's teeth. NEBULIZER — is a piece of medical equipment that a person with asthma or another respiratory condition can use to administer medication directly and quickly to the lungs. A nebulizer turns liquid medicine into a very fine mist that a person can inhale through a face mask or mouthpiece. Taking medicine this way allows it to go straight into the lungs and the respiratory system where it is needed Avvariety of nebulizers are available to generate aerosols for inhaled drug delivery. There has recently been increased Interest in the use of nebulizers due to the high cost of HFA (hydrofluoroalkane) formulations. A liquid solution or suspension is added to the nebulizer for each treatment. Traditionally, nebulizers and the drug formulation are marketed separately. Increasingly, formulations introduced to the market are intended for use with a specific nebulizer. Moreover, a variety of nebulizer designs are now available, 1. Jet Nebulizers Ajet nebulizer is a medical device which converts liquid medication into an aerosolized mist which is easy to inhale. Jet nebulizers are used in the treatment of a range of pulmonary conditions. They are also known simply as nebulizers or atomizers. A jet nebulizer is used when a patient might have difficulty taking medication in other ways, such as with a metered dose inhaler. These devices are often used in hospital settings when a lot of medication needs to be delivered to the patient's lungs quickly, as when a patient is in respiratory distress. They can also be used at home for breathing treatments, A jet nebulizer delivers compressed gas through a jet (see image below].This causes a region of negative pressure, in which a solution or suspension is entrained into the gas stream and Is sheared into a liquid film. This film is unstable and breaks into droplets due to surface tension forces. A baffle in the aerosol stream produces smaller particles, and itis further conditioned by factors such as the relative humidity of the carrier gas. Student Nurse’s Copy dn. Scanned with CamScannernen] = sees cat wel i) auc Tone JET NEBULIZER “ oy ne ite Sa Compressed gas source The volume of solution that is trapped inside the nebulizer's dead volume is typically 0.5~1 ml, To reduce dead volume, clinicians and patients commonly tap the nebulizer cup in an effort to increase nebulizer output, but therapy continued past the point of sputtering in an attempt to decrease the dead volume is unproductive and is not recommended, Due to evaporative losses within the nebulizer, the solution becomes increasingly concentrated and cools during nebulization. Unless designed for a smaller or larger fill volume, the nebulizer should be filled to 4-5 ml. Because the volume of some tunit-dose medications is suboptimal, the formulation should be diluted to a volume to 4-5 ml, The increased nebulization time associated with a greater fill volume can be offset by increasing the flow used to power the nebulizer. Increased flow also decreases the droplet size produced by nebulizers. A flow of 6-8 L/min is recommended unless the nebulizer is designed specifically for a flow other than this. In the home setting, jet nebulizers are used with a compressor. Often the nebulizer and compressor are provided as 2 unit, both from the same manufacturer. The flow and pressure characteristics of compressor/nebulizer units affect nebulizer output. For reasons such as cost, clinicians and patients might not follow recommendations to use compressor/nebulizer combinations. 2. Mesh Nebulizers Mesh nebulizers use a mesh or plate with multiple apertures to produce an aerosol (See image below). Mesh nebulizers have very low residual volume, fast treatment time, and the ability to nebulize a variety of solutions and suspensions. ‘These devices are powered by batteries or electricity, and an external gas flow is not required. ea No With active mesh febulizers (vibrating mesh), a vibrational element contracts and expands, moving a domed aperture plate with > 1,000 tapered holes. The holes are larger on the liquid side and smaller on the side from which the droplets emerge. Passive mesh nebulizers use a piezoelectric crystal that vibrates a transducer horn interacting with the liquid formulation and a static aperture plate, which pushes fluid through the mesh. For both active and passive designs, the drug is placed in the reservoir of the nebulizer above the aperture plate. Particle size and aerosol flow are determined by the exit diameter of the holes on the aperture plate. There is the potential for the pores of the nebulizer to become ‘Student Nurse's Copy Sn Scanned with CamScannerclogged with some suspensions or viscous drugs. The reliability of vibrating mesh nebulizers has also been questioned, with one report finding that nebulization was often randomly interrupted with a wide range of retained volumes. Aerosol delivery from a mesh nebulizer has been reported to be greater than that of a jet nebulizer. Delivery efficiency of a mesh nebulizer may be > 3 times that of jet nebulizers, and thus drug doses may need to be adjusted. A holding chamber can be used with the mesh nebulizer to collect aerosol during exhalation, further increasing the dose on the subsequent inhalation. Mesh nebulizers are more expensive than jet nebulizer/compressor systems. Mesh nebulizers are available for use by ambulatory patients, and systems are also available for use during invasive and noninvasive ventilation. Aztreonam(an antibiotic for cystc fibrosis) and glycopyrrolate (a long-acting muscarinic antagonist for COPD) are examples of FDA-cleared drugs for inhalation using a mesh nebulizer. 3, Ultrasonic Nebulizers Ultrasonic nebulizer, on the other hand, contains a transducer instead of a compressor. The transducer is a crystal. It produces ultrasonic sound waves that convert the medicated liquid into vapors. Ultrasonic nebulizers are quiet. The sound levels of the sound waves are higher than what human ears can detect. Also, because they do not have @ ‘compressor, ultrasonic nebulizers are not heavy. There are even portable ultrasonic nebulizers that are battery operated. The downside of ultrasonic nebulizers is they are not compatible with some medicines for asthma and other respiratory diseases. There are medicines that become ineffective when they are turned into mist using ultrasonic sound waves. Some could even cause negative effects to the patient, Ultrasonic nebulizers convert electrical energy to high-frequency ultrasonic waves. The ultrasonic waves are transferred to the surface of a liquid, thus producing an aerosol (Shown in the image below). Small-volume ultrasonic nebulizers are commercially available for delivery of inhaled bronchodilators. Their cost is greater than that of jet nebulizer/compressor systems but comparable to that of mesh nebulizers. A drug/device combination that uses an ultrasonic nebulizer is the treprostinil/Tyvaso system. Use of these devices has been hampered by their tendency for ‘mechanical malfunction. A potential issue with the use of ultrasonic nebulizers is the possiblity for drug inactivation by the ultrasonic waves, although this has not been shown to occur with common aerosol medications. The ultrasonic nebulizer is inefficient in nebulizing a suspension. ‘Acoustic waves Drug solution Piezoelectric ‘transducer There are many challenges with the use of inhalers and nebulizers, and no one device suits all patients. Challenges range from difficulties related to lung disease severity to physical impediments. In terms of device selection and adherence, patient engagement and satisfaction are important to consider. Each device has different technical properties, so a personalized approach to the selection of the most appropriate device is recommended to achieve desired clinical ‘outcomes for each patient. If an inhaler does not produce optimal results, the patient may, become non-adherent. Furthermore, the use of multiple types of devices can present challenges to patients. ADMINISTERING INHALED MEDICATIONS BY NEBULIZERS Purpose: 1. To administer medication directly and quickly to the lungs. Student Nurse’s Copy 6 Scanned with CamScanner2. To assist the removal of accumulation of lung secretion, To prevent accumulation of secretions in client's at risk, e.g. Those patient on mechanical ventilators. To relieve dyspnea 4 27 aie ¢ | Meson * Using a Nebulizer with'a Mouthpiece, {In some cases, nebulization is restricted or avoided due to possible untoward results or rather decreased effectiveness such as: 1. Patients with unstable and increased blood pressure 2. Individuals with cardiac irritability (may result to dysrhythmias) 3. Persons with increased pulses 4. Unconscious patients (inhalation may be done via mask but the therapeutic effect may be significantly low) ‘Advantages of Nebulization This therapy works for children who are unable to use any other inhalation device. The nebulizer allows the drug to reach the lungs directly where itis needed. Through this, the medicine gets effected very quickly. Itis very effective for asthma patients. This process is not painful for the patient. It can be used to overcome respiratory problems as well as in severe respiratory emergencies. Disadvantages of Nebulization If the mask/mouthpiece is not cleaned properly after prolonged use, it may cause an infection in the lungs. Inits use, a large amount of the drug is wasted through gas which escapes from the side of the mouthpiece, Its use in diseases like asthma is more expensive than that of an ordinary inhaler. ‘The drugs used in it are responsible for most of the side effects caused by this therapy. But in some cases, the problems caused to the patient can also be due to nebulization. ‘These problems are as follow: shivering Headache Increase heart rate Dry mouth NOTE: This intense debate with diametrically opposed opinions, does not clarify whether it is appro} nebulizers during this COVID-19 pandemic. However, it has been rightly pointed out that there are no known infection- related hazards to an uninfected patient and even to a patient with COVID-19 that preclude the use of a nebulizer at home . In any case, if the patient follows social distancing guidelines, undertakes extra precautions such as increased nebulizer hygiene, avoidance of nebulizer use in the presence of other people, and ensures that the nebulizer treatment is done near open windows or in areas of increased air circulation, the risks toward other people can be minimized as, ‘well. Things are different when the patient is treated in hospital. Health care personnel must be protected from SARS- Student Nurse’s Copy Iu Scanned with CamScannerCov-2 infecti adherence to stringent sanitization protocols and use of personal patients. Furthermore, the use of negative-pressure rooms, disposing x ‘maintaining at least 6 feet (1.8 m) or greater distance from the patient should be considered when 2 pat undergoing nebulized treatment. Equipment: Nebulizer and nebulizer connecting tubes * Compressor oxygen tank or Portable Nebulizer Machine ‘+ Mouthpiece/mask ‘+ Respiratory medication to be administered ‘+ Normal saline solution ADMINISTERING INHALED MEDICATIONS BY NEBULIZERS oS . Therefore, hospitals and health care facilities should continue to adhere to strict measures, including protective equipment in the presence of COVID-19 of used equipment after each use, and | tient is eee 7 Scar OB HE ee 1. Introduce self to patient. Identify patient using two patient-identifiers. Rationale: To ensure patient safety and reliability of the patient's identification process. ‘Good morning Ma'am/Sir! | am Nurse Joana. | willbe the nurse in-charged for your Nebulization today. Please state your complete name and birthday, Ma‘am/sir. Thank you! 2.Check patient ’'s vital signs prior to Nebulization administration. Rationale: Provides baseline assessment. Immediate reaction can develop once procedure begins. Determine a baseline respiratory assessment prior to administration of medication, Before administering the nebulization, lam going to check your vital signs first, Sir/Ma’am. Soto start, 'l check your temperature first followed by your BP, RR and HR. Thank you! +3. Check MAR (Medication Administration Record) against doctor’s orders. Rationale: Careful checking helps prevent medication errors. ‘4. Perform the TEN RIGHTS x3 (must be done with each individual medication): 1. Right Drug. 2. Right Patient. 3. Right Dose. 4, Right Route. 5. Right Time and Frequency. 6. Right Documentation. 7. Right History and Assessment. 8. Drug approach and Right to Refuse. 9. Right Drug-Drug Interaction and Evaluation. 10. Right Education and Information, Rational checking helps prevent medication errors, careful '5. Assemble nebulizer as per manufacturer's instructions. Rationale: Assembly specific to manufacturer's instructions ensures proper delivery of medication. 6. Add medication as prescribed by pouring medication into. the nebulizer cup. «Some medications may be mixed together if there Student Nurse's Copy Scanned with CamScannerare no contraindications. * Some medications may require the addition of saline per prescription for dilution. Rationale: This step ensures the proper delivery of medication. 7. Use a mask if patient is unable to tolerate a mouthpiece, and an adaptor specific to tracheostomies if the patient has a tracheostomy. Rationale: This ensures the proper delivery of medication, 8. Perform hand hygiene. Rationale: Reduces transmission of microorganisms and eliminating uncontrallable sources of infection. 3. Position patient sitting up in a chair or in bed at greater than 45 degrees. Rationale: This position improves lung expansion and medication distribution. NOTE: Attach the nebulizer to compressed air if available; Use oxygen if there is no compressed air. If patient is ‘receiving oxygen, do not turn it off. Continue to deliver ‘oxygen through nasal prongs with the nebulizer. 10. Turn on air to nebulizer and ensure that a sufficient mist is visible exiting nebulizer chamber. A flow rate of 6 to 10L should provide sufficient misting. Ensure that nebulizer chamber containing medication is. securely fastened. Ensure that chamber is connected to face mask or mouthpiece, and that nebulizer tubing is. connected to compressed air or oxygen flow meter. Rationale: This process verifies that equipment is working properly. 11. If mouthpiece Is being used, ensure lips are sealed around mouthpiece. Rationale: Sealed lips ensure proper inhalation of medication 112. Have patient take slow, deep, inspiratory breaths. Encourage a brief 2- to 3-second pause at the end of inspiration, and continue with passive exhalations. Rationale: This maximizes effectiveness of medication. Note: if patient is dyspneic, encourage holding every fourth or fifth breath for § to 10 secands. 13. Have patient repeat this breathing pattern until ‘medication is complete and there is no visible mis process takes approximately 8 to 10 minutes. Rationale: This maximizes the effectiveness of the medication. i This 14. Tap nebulizer chamber occasionally and at the end of the treatment. Rationale: This action releases drops of ‘medication that cling to the side of the chamber, Ma’am/Sir let me tap the chamber of your nebulizer to release the remaining medication. Thank you Ma’am! 15. Monitor patient's pulse rate during treatment, especially if beta-adrenergic bronchodilators are being ‘Ma‘am/Sir please let me monitor your Pulse Rate. Student Nurse's Copy On Scanned with CamScannerused, Rationale: eta-adrenergic bronchodilators have cardiac effects that should be monitored during treatment. Thank You! 16. Once treatment is complete, turn flow meter off and disconnect nebulizer. Rationale: This promates patient comfort and safety. 17. Properly clean, rinse, dry, and store nebulizer as per agency policy. Rationale: Proper care reduces the transfer of ‘microorganisms. 18. IFinhaled medication included steroids, have patient rinse mouth and gargle with water/warm water after treatment. Rationale: Rinsing removes residual medication from mouth ond throat, and helps prevent oral candidiasis related to steroid use Ma’am/sir, let me offer you a glass of water so ‘you can gargle and rinse your mouth and throat. Please spit the water out of your mouth. Thank youl 19. Once treatment is complete, encourage patient to perform deep breathing and coughing exercises to help remove or expectorate mucous. Rationale: Treatments are often prescribed specifically to encourage mucous expectoration. ‘Wa’am/Sir if you able let's do the deep breathing and coughing exercise. Please do this for three times. You can do this often to loosen or remove secretions. 20. Return patient to a comfortable and safe position, Rationale: This promotes patient comfort and safety. ‘Ma’am/Sir let me put you in your most ‘comfortable position. Are you comfortable with this position Ma’am/sir? Thank yout ‘Your call bell is right beside you in case you need something. | will be right back to check on you. Thank you Ma‘am/Sir! 21, Perform hand hygiene. Rationale: Reduces transmission of microorganisms and eliminating uncontrollable sources of infection. 22. Document treatment as per agency policy, and record and report any unusual events or findings to the appropriate health care provider. Rationale: Accurate and timely documentation and reporting promote patient safety. Student Nurse's Copy 10 Scanned with CamScannerADMINISTERING INHALED MEDICATIONS BY NEBULIZERS PERFORMANCE EVALUATION CHECKLIST Name of Student: Level & Black: ‘School Year & Term: Overall Rating : PERFORMED UNABLE WITH To REMARKS ASSISTANCE PERFORM as 23 0-4 Proceoure| PERFOMED INDEPENDENTLY 1. Introduce self to patient. 2. Check patient's vital signs prior Nebulization administration. 3. Check MAR (Medication Administration Record) against doctor's orders. 4, Perform the TEN RIGHTSx3 (must be done with each individual medication) '5. Assemble nebulizer as per manufacturers instructions. 6. Add medication as prescribed by pouring ‘medication into the nebulizer cup. 7. Use a mask if patient is unable to tolerate a mouthpiece, and an adaptor specific to tracheostomies if the patient has a tracheostomy. 8. Perform hand hygiene. ‘9. Position patient sitting up in a chair or in bed at greater than 45 degrees. 10. Turn on air to nebulizer and ensure that a sufficient mist is visible exiting nebulizer chamber. A flow rate of 6-10 L should provide sufficient misting. Ensure that nebulizer chamber containing medication is securely fastened. Ensure that chamber is connected to face mask or mouthpiece, and that nebulizer Student Nurse’s Copy dn Scanned with CamScannertubing is connected to ‘compressed air or oxygen flow meter. 11. If mouthpiece is being used, ensure lips are sealed around mouthpiece. 12. Have patient take slow, deep, inspiratory breaths Encourage a brief 2 to 3- second pause at the end of inspiration, and continue with passive exhalations. 13. Have patient repeat this breathing pattern until medication is complete and there is no visible misting, This process takes approximately 8 t0 10 minutes. 14, Tap nebulizer chamber occasionally and at the end of the treatment. 15. Monitor patient's pulse rate during treatment, especially if beta-adrenergic bronchodilators are being, used. 16. Once treatment is complete, turn flow meter off and disconnect nebulizer. 17. Rinse, dry, and store nebulizer as per agency policy. 18. Ifinhaled medication included steroids, have patient rinse mouth and gargle with water/warm water after treatment. 19. Once treatment is complete, encourage patient to perform deep breathing and ‘coughing exercises to help remove or expectorate mucous. 720. Return patient toa comfortable and safe position. 21. Perform hand hygiene. 22. Document treatment as per agency policy, and record and report any unusual events Student Nurse's Copy 126 Scanned with CamScanner or > hear,findings to the appropriate : health care provider. Remarks: Conforme: Student's Signature Clinical instructor B. METERED DOSE INHALERS Inhaled respiratory medications are often taken by using a device called a metered dose inhaler, or MDI. The MDI is 2 Pressurized canister of medicine in a plastic holder with a mouthpiece. When sprayed, it gives a reliable, consistent dose of medication. ‘There are two methods for using an MDI. In many cases; the preferred method is with a device called a valved holding shamber (Figure 1). These devices attach to the MDI and hold the "spray" of medication. They make it easier to use the ‘MOI and help get the medication into the lungs better. An MDI can also be used without a chamber (Figure 2). These methods are described below. Your healthcare professional will decide which method is most appropriate for you. Priming: Priming (spraying one or more puffs into the air before use) assures that the inhaler is ready to use and will dispense the correct amount of medication. Priming varies between devices, so it is important to read the patient instructions that come with your medication. Figure 1: MD with a valved holding chamber Figure 2: MI without a chamber HAND ( Metered Dose) nebulizer- is a container of medication that can be compressed by hand to release the medication through a nose-piece or mouthpiece. Inhaler Devices 1. Pressurized Metered-Dose Inhalers (pMDI) ‘The pMDI was the first widely used multi-dose portable inhalational device. Virtually every patient with COPD and asthma either uses or has used a pMDI, most often as albuterol and/or ipratropium. All inhaled drug classes for ‘Student Nurse's Copy 13m Scanned with CamScanner‘obstructive lung diseases are available in a pMDI as single or combination products. Yet the pMDI is one of the most challenging devices for patients to use correctly. The pMDI is a multi-dose, pressurized, aluminum canister that, when actuated, delivers drug through a metering valve and orifice (Shown in the image below). The formulation is either solution, suspension, or ‘co-suspension and contains ‘other components such as propellant, suspending agents, co-solvents, and surfactants. (eg, lecithin or oleic acid, which are soy derivatives). Excipients infrequently cause adverse effects. Surfactants aid in decreasing particle crystal agglomeration. The interior wall of the canister is coated to decrease adhesion and potential for interaction with ‘components in the formulation. Drug crystals in some pMDIs flocculate, leading to sedimentation. A new formulation, 2 co-suspension technology, represents a significant advance. It uses phospholipid particles to reversibly attach to drug molecules to provide more uniform suspension, facilitate pharmaceutical compatibility of drug combinations, and Provide more consistent drug delivery as well as relying less on the need for shaking prior to use. Due to differences in boiling temperatures between the drug formulation and room air, when drug reaches the air, it immediately evaporates and aerosolizes small droplets. {guid phan Gormulation) NOTE: (COVID 19) According to the updated version of GINA (Global Initiative for Asthma) strategy, where possible, use of nebulizers must be avoided because of the risk of transmitting infection to other patients and to healthcare workers. in fact nebulizers can transmit respiratory viral particles for approximately 1 meter. Instead, the recommendation is to Use @ pMDI and spacer, with a mouthpiece or tightly fitting facemask, if required, when short-acting B2-agonist must be delivered to treat an acute asthma episode in adults and children. ‘Spacers and Holding Chambers \VHCs (Valved Holding Chambers) and spacer devices are used to overcome some of the limitations of pMDI. A spacer is a simple tube or extension with no valves to contain the aerosol, whereas a VHC is an extension device with a 1-way valve that, when the attached pMDI is actuated, holds the aerosol until inhalation, although impaction on the inner walls occurs shortly after actuation. Spacers and VHCs allow deceleration of the aerosol plume and, in the case of the latter, trap the aerosol cloud until the patient inhales. However, their availability and coverage by payers is suboptimal in some settings. Although the word spacer is often used forall types of extension add-on devices, these devices are best categorized as either as a spacer or a VHC. Vics (VALVED HOLDING CHAMBERS) AND SPACER DEVICES Student Nurse's Copy te Scanned with CamScanner So2. Soft Mist Inhalers The SMI (Respimat, Boehringer Ingelheim, Ingelheim am Rhein, marketed with ipratropium/albuterol and More recently with lor Respimat does not use Propellants, as the drug is released via a ‘through a membrane, emitting a small-particle aerosol. The m discarded after all doses are used. It is the only liquid aerosol i of puffs are reached. Shaking is not necessary prior to using tl Germany) is the newest type of inhaler, initially ng-acting bronchodilators (See image below). The compressed spring inside the inhaler that pushes drug fedication canister is inserted into the inhaler, and both are inhaler that stops emitting doses when the stated number he device. i « —— rh [ —- 3. Dry Powder Inhalers Pls have become very popular in recent years, due in part to the ban on CFCs (chlorofluorocarbon), which has facilitated the development of new formulations, and they are user-friendly (See image below). OPI formulations often have excipients because of pharmaceutical formulation issues, and some patients perceive they are not receiving any drug if they do not taste it (eg, lactose excipient). Breath-actuated DPIs may overcome the difficulties with coordination of inhaler actuation and inspiration, but errors still exist, such as inadequate effort. The DPI requires each dose to be loaded, whether as a separate capsule or by advancing powder into position by some steps. A 8 DPls derive the energy for drug delivery by the patient's inspiratory effort, which is greater than that required for a medication administered as a liquid aerosol. The inspiratory effort required to adequately deliver medication varies among DPls. Some require more effort than others, and some are more susceptible to variations in flow than others. Failure to exhale to functional residual capacity, but not residual volume, before inhaling through a DPI and failure to use a forceful, deep inhalation were 2 of the most ‘common problems with DPis, The recommended minimum inspiratory effort among different DPI manufacturers has a range of 30-60 L/min ADMINISTERING INHALED MEDICATIONS USING METERED DOSE INHALERS. PURPOS! 1. To administer medication directly and quickly to the lungs. 2. To assist the removal of accumulation of lung secretion. 3. To prevent accumulation of secretions in client's at risk, e.g.Those patient on mechanical ventilators. Student Nurse's Copy 150 Scanned with CamScanner4.To relieve dyspnea ADMINISTERING INHALED MEDICATIONS USING METERED DOSE INHALERS Te PROCEDURE a By he eae 1. Introduce self to patient. Identify patient using two patient- identifiers. Rationale: To ensure patient safety and reliability of the patient's identification process. Good morning Ma’am/sir! | am Nurse Joana. | wll be the nurse in-charged for your Nebulization today. Please state your complete name and birthday, Ma’am/Sir. Thank you! 2, Check patients vital signs prior to nebulization administration. Rationale: Provides baseline assessment. Immediate reaction can develop once procedure begins. Before administering the nebulization, | am going to check your vital signs first, Sir/Ma'am. So to start, I check your temperature first followed by your BP, RR and HR, Thank you! '3. Review physician’s medication order, including client name, drug name, dose, no. of inhalations, and time of administration. Rationale: Ensure safe and correct administration of medication ‘Perform the TEN RIGHTS x 3 (must be done with each individual medication): 1. Right Drug. 2. Right Patient. 3. Right Dose. 5. Right Time and Frequency. 6. Right Documentation. 7. Right History and Assessment. 8. Drug approach and Right to Refuse. 9. Right Drug-Drug Interaction and Evaluation. 10. Right Education and Information. Rationale: Ensure safe and correct administration of medication '5. Wash hands. Rationale: Prevents transmission of ‘microorganisms. 6. Assist client’s ability to hold and manipulate inhaler. Rationale: Impairment of grasp or hand tremors interfere with ability to depress canister with inhaler. 77. Assess drug schedule and no. of inhalations prescribed for each dose. Rationale: Influences explanations nurse provides for use of inhaler. 8. Have client prepare following equipment and supplies: ‘a, Metered dose inhaler with medication canister b. Facial Tissues (optional) . Wash basin or sink with warm water. d. Paper Towel Rationale: Saves Time and Effort. Use to clean inhaler ‘9 Instruct client in comfortable environment by sitting in chair in hospital room or kitchen table in home. Rationale: Client will be more likely remain perceptive of nurse’s explanations. 10, Allow client to manipulate inhaler and canister. Explain and demonstrate how canister fits into inhaler. Rationale: Client must be familiar with how to use the equipment 11. Explain metered dose and warn client about over-use of Student Nurse's Copy 16 Scanned with CamScanner inhaler, ji Rationaleinhaler, including drug side effects. Rationale: Client must not arbitrarily decide to administer excessive inhalations because of risks of serious side effects. 12. Explain to client that gagging sensation in throat caused by droplet of medication on pharynx or tongue may be felt. Rationale: Results when inhalant is sprayed and inhaled incorrectly 13. Explain steps used to administer inhaled dose of medication. (Demonstrate steps if possible), a. Remove mouthpiece cover from inhaler. b. Open lips and place inhaler in mouth with opening toward back of throat. c. Exhale fully, then grasp mouthpiece with teeth and lips while holding inhaler with thumb at mouthpiece and index and middle fingers at top. d. While inhaling slowly and deeply through mouth, fully depress medication canister once. e. Hold breath for approximately 10 sec. £. Remove inhaler. . Exhale through pursed lips. Rationale: Use of simple step-by-step explanations allows clients to.ask questions, Nurse demonstrates actual depression of, canister without self-administering drug dose. Medication should not escape through mouth, Medication Is distributed to airways during inhalation. Inhalation through mouth rather than nose draws medication more effectively into airways. Allow tiny drop of aerosol spray to reach deeper branches of oirways. Pursed lip breathing keeps small airways open during exhalations. ‘Ma’am/Sir if this is your first time to use the MDI let me demonstrate to you how to use it. 174, Instruct client to wait 5 to 10 minutes between inhalation or as ordered by the physician. Rationale: Drugs must be inhaled sequentially. First inhalation open airways and reduces inflommation. Second and third inholations penetrate deeper airways. 15. Instruct client against repeating inhalations before next scheduled dose. Rationale: Drugs are prescribed at intervals to provide constant bronchodilation and minimize side effects. 16. Instruct client in removing medication canister and cleaning inhaler in warm water. Rationale: Accumulation of spray around ‘mouthpiece can interfere with proper distribution during use. 17. Ask client if he/she has any questions. Rationale: Provides ‘opportunity to clarify misconceptions or misunderstanding. 18. Have client demonstrate use of inhaler and explain drug scheduled, Provides feedback for measuring client's learning. Rationale: Improves likelihood of compliance with therapy. Student Nurse's Copy 1 Scanned with CamScanner19. Wash Hands. Rationale: Prevents transmission of ‘microorganisms. 20. Describe in nurse’s notes content of skills taught, cients ability to perform skill, as well as drug and dose administered. Rationale: Provides continuity to teaching plan so that other members of nursing staff will not teach same material follow suppl ‘Ma’am/Sir your call bell is right beside you in case you need something. ) | will be right back to check on you. Thank you Ma’ am/sir! ADMINISTERING INHALED MEDICATIONS USING METERED DOSE INHALERS (MDI) PERFORMANCE EVALUATION CHECKLIST a School Year & Tert Name of Student Level & Block: Overall Rating —= PERFORMED [UNABLE ma NDEPENOENTEY ASSISTANCE PERFORM a5 23 ot PROCEDURE L introduce selfto patient. Identify patient using two patient-identifiers. 2. Check patient's vital signs prior Nebulization administration, 3. Review physician's medication order, including client name, drug name, dose, no. of inhalations, and time of administration. 4.Perform the TEN RIGHTS x3 (must be done with each individual medication): 5. Wash hands. 6, Assist client's ability to hold and manipulate inhaler. 7. Assess drug schedule and no. of inhalations prescribed for each dose. 8. Have client prepare Student Nurse's Copy 186, Scanned with CamScannerfollowing equipment and supplies: a, Metered dose inhaler with medication canister b. Facial Tissues (optional) . Wash basin or sink with warm water. 4. Paper Towel 9. Instruct or bring client in comfortable environment by sitting in chair in hospital room or kitchen table at home. 10. Allow client to manipulate inhaler and canister. Explain and demonstrate how canister fits into inhaler. 11. Explain metered dose and warn client about over-use of inhaler, including drug side 12. Explain to client that gagging sensation in throat caused by droplet of ‘medication on pharynx or tongue may be felt. 13. Explain steps used to administer inhaled dose of medication. (Demonstrate steps if possible). a. Remove mouthpiece cover from inhaler. b. Open ips and place inhaler in mouth with opening toward back of throat. . Exhale fully, then grasp mouthpiece with teeth and lips while holding inhaler with ‘thumb at mouthpiece and index and middle fingers at top. ' d. While inhaling slowly and deeply through mouth, fully depress medication canister once. . Hold breath for approximately 10 sec. £, Remove inhaler. Student Nurse's Copy 198 Scanned with CamScanner2. For patier osocomial i &, Exhale through pursed lips. 14. Instruct client to wait 5 to 10 minutes between inhalati or as ordered by the physician, 15. Instruct client against ‘repeating inhalations before Next scheduled dose, J 16. Instruct client in removing ‘medication canister and cleaning inhaler in warm water. 17. Ask client if he/she has any questions. . 18. Have client demonstrate Use of inhaler and explain drug scheduled. Provides feedback for measuring client's learning. 19. Wash Hands. 20. Describe in nurse’s notes content of skills taught, client's ability to perform ski as drug and dose administered. Remarks: Conforme: Student's Signature CHECK FOR UNDERSTANDING ‘A. NEBULIZER ‘Multiple Choice: (10 points) Read and analyze each sentence/situation carefully and encircle the letter of the correct. answer then write the rationale. 1. An ultrasonic nebulizer set at maximum amplitude is producing an insignificant quantity of mist. All of the following procedures could be done to improve the performance of the nebulizer except: ‘A. Checking the quantity of liquid in the coupling chamber. . Heating the solution cup with an immersion heater. C. Increasing the gas flow from the blower unit, D.Checking the quantity of liquid in the medication cup. RATIONALE: Student Nurse's Copy 20% Scanned with CamScanner wumedition