SKILL

5-23 Administering Medication via a Small-Volume Nebulizer

Many medications to help with respiratory problems may be delivered via the
respiratory system using a small-volume nebulizer. Nebulizers disperse the fine
particles of liquid medication into the deeper passages of the respiratory tract, where
absorption occurs. The treatment continues until all the medication in the nebulizer
cup has been inhaled.

Equipment  Stethoscope
 Medication
 Nebulizer tubing and chamber
 Air compressor or oxygen hookup
 Sterile saline (if not premeasured)
 Medication Administration
Record (MAR) or Computerized
medication Administration
Record (CMAR)

Assessment Assess lung sounds pre- and post use to establish a baseline and determine the effectiveness
of the medication. Often, patients have wheezes or coarse lung sounds before medication
administration. If ordered, assess patient’s oxygenation saturation level before medication
administration. The oxygen level will usually increase after the medication has been
administered. Verify patient’s name, dose, route, and time of administration. Assess the
patient’s knowledge and understanding of the medication’s purpose and action.

NURSING Determine the related factors for the nursing diagnoses based on the patient’s current
DIAGNOSIS status. Appropriate nursing diagnoses may include:

 Deficient Knowledge
 Ineffective Airway Clearance
 Risk for Activity Intolerance
 Ineffective Breathing Pattern
 Impaired Gas Exchange

OUTCOME
The expected outcome to achieve is that the patient receives the medication. Other
IDENTIFICATION
outcomes that may be appropriate include the following: patient exhibits improved
AND PLANNING
lung sounds and respiratory effort; patient demonstrates steps for use of nebulizer;
and verbalizes understanding of medication purpose and action
SKILL
5-23 Administering Oxygen by Nasal Cannula(continued)
IMPLEMENTATION
ACTION
1. Gather equipment. Check each
medication order against the original
physician’s order according to agency
policy. Clarify any inconsistencies. Check
the patient’s chart for allergies.
2. Know the actions, special nursing
considerations, safe dose ranges, purpose
of administration , and adverse effects of
the medication to be administered.
Consider the appropriateness of the
medication for this patient.
3. Perform hand hygiene.
4. Move the medication cart to the outside
of the patient’s room or prepare for
administration in the medication area.
5. Unlock the medication cart or drawer.
Enter pass code and scan employee
identification, if required.
6. Prepare medication for one patient at a
time.
7. Read the MAR and select the proper
medication from the patient’s medication
drawer or unit stock.
8. Compare the label with the MAR. Check
expiration dates and perform calculations,
if necessary. Scan the bar code on the
package, if required.
9. When all medication for one patient have
been prepared, recheck the label with the
MAR before taking them to the patient.
Lock the medication cart before leaving it.
RATIONALE RATINGS
This comparison helps to identify errors that
may have occurred when orders were
transcribed. The physician’s order is the legal
record of medication orders for each agency.
The knowledge aids the nurse in evaluating
the therapeutic effect of the medication in
relation to the patient’s disorder and can also
be used to educate the patient about the
medication.
Hand hygiene prevents the spread of
microorganisms.
Organization facilitates error-free
administration and saves time.
Locking of the cart or drawer safeguards each
patient’s medication supply. Hospital
accrediting organizations require medication
carts to be locked when not in use. Entering
pass code and scanning ID allows only
authorized users into the system and
identifies user for documentation by the
computer.
This prevents error in medication
administration.
This is the first check of the label.
This is the second check of the label. Verify
calculations with another nurse to ensure
safety, if necessary.
This is a third check to ensure accuracy and
prevent errors. Locking the cart or drawer
safeguards patient’s medication supply.
Hospital accrediting organizations require
medication carts to be locked when not in
use.
 SKILL
5-23 Administering Medication via a Small-Volume Nebulizer
ACTION
10. Transport medications to the patient’s
bedside carefully, and keep the medications
in sight all times.
11. Ensure that the patient receives the
medications at correct tome.
12. Identify the patient. Usually, the patient
should be identified using two methods.
Compare information with the MAR or
CMAR.
a. Check the name and
identification number on the
patient’s identification band.
b. Ask the patient to state his or her
name.
c. If the patient cannot identify him
or herself, verify the patient’s
identification with a staff member
who knows the patient for the
second source.
13. Complete necessary assessments before
administering medications. Check allergy
bracelet or ask patient about allergies.
Explain what you are going to do and the
reason to the patient.
14. Scan the patient’s bar code on the
identification band, if required.
15. Perform hand hygiene.
16. Remove the nebulizer cup from the
device and open it. Place premeasured unit-
dose medication in the bottom section of
the cup or use a dropper to place
concentrated dose of medication in cup and
add prescribed diluent, if required.
17. Screw the top portion of the nebulizer
cup back in place and attach the cup to the
nebulizer. Attach one end of tubing to the
stem on the bottom of the nebulizer cuff
and the other end to the air compressor or
oxygen source.
RATIONALE RATINGS
Careful handling and close prevent accidental
or deliberate disarrangement of medications.
Check agency policy, which may allow for
administration within a period of 30 minutes
before or 30 minutes after designated time.
Identifying the patient ensures the right
patient receives the medications and helps
prevent errors.
This is the most reliable method. Replace the
identification band if it is missing or
inaccurate in any way.
This requires a response from the patient, but
illness and strange surroundings often cause
patients to be confused.
This is another way to double check identity.
Do not use the name on the door or over the
bed, because these may be inaccurate.
Assessment is a prerequisite to
administration of medications. Explanation
relieves anxiety and facilitates cooperation.
Scanning provides additional check to ensure
that the medication is given to the right
patient.
Hand hygiene deters the spread of
microorganisms.
To get enough volume to make a fine mist,
normal saline may need to be added to the
concentrated medication.
Air or oxygen must be forced through the
nebulizer to form a fine mist.
 ACTION RATIONALE RATINGS

18. Turn on the air compressor or oxygen.
Check that a fine medication mist is
produced by opening the valve. Have
patient place mouthpiece into mouth and
grasp securely with teeth and lips.
If there is no fine mist, make sure that
medication has been added to the cup and
that the tubing is connected to the air
compressor or oxygen outlet. Adjust flow
meter if necessary.

19. Instruct patient to inhale slowly and
deeply through the mouth. A nose clip may
necessary if patient is also breathing
through nose. Hold each breath for slight
pause, before exhaling.
While the patient inhales and holds the
breath, the medication comes in contact with
the respiratory tissue and is absorbed. The
longer the breath is held, the medication can
be absorbed.

20. Continue this inhalation technique until
all medication in the nebulizer cup has been
aerosolized (usually about 15 minutes).
Once the fine mist decreases in amount,
gently flick the sides of the nebulizer cup.
Once the fine mist stops, the medication is no
longer being aerosolized. By gently flicking
the cup sides, any medication that is stuck to
the sides is knocked into the bottom of the
cup, where it can become aerosolized.

21. If desired, have the patient gargle with

tap water after using nebulizer. Clean the
nebulizer according to the manufacturer’s
directions.
22. Reassess lung sounds, oxygenation
saturation if ordered, pulse, and
respirations.
23. Perform hand hygiene.
Rinsing is necessary when using inhaled
steroids, as oral fungal infections can occur.
Rinsing removes medication residue from the
mouth. The buildup of medication can affect
how the medication is delivered, as well as
attract bacteria.
Lung sounds and oxygenation saturation may
improve after nebulizer use. Respirations may
decrease after nebulizer use. Check for
adverse effect of medications. Some
medications can cause tachycardia.
Hand hygiene deters the spread of
microorganisms.

EVALUATION The expected outcome is met when the patient receives the medication and
exhibits improved lung sounds and respiratory effort. In addition, the patient
demonstrates correct steps for use and verbalizes an understanding of the
need for medication.

DOCUMENTATION

Guidelines Document respiratory rate, oxygen saturation if appropriate, and lung

sounds. Document medication administration on MAR or CMAR immediately
after administration. Document patient teaching and patient response, if
appropriate.

Sample Documentation
9/29/08 Wheezes noted in all lobes of lungs before albuterol nebulizer, o₂ saturation 92%,
respiratory rate 24 breaths per minute, patient reports “feeling I can’t get my breath”. After
albuterol treatment, lung sounds are clear and equal in all lobes, O₂ saturation 97%,
respiratory rate 18 breaths per minute. Patient verbalizes relief of shortness of breath and an
understanding of medication purpose and action.－ C. Bausler, RN
Unexpected Situations and Patient reports that nebulizer doesn’t smell or taste the way it usually
Associated Interventions does: Double-check to make sure that medication was added to nebulizer
cup and that it is the appropriate medication.

Special Considerations

General Considerations  Ongoing assessment is an important part of nursing care to evaluate

patient response to administered medication and early detection of adverse
effects. If an adverse effect is suspected, withhold further medication doses
and notify the patient’s primary health care provider. Additional
intervention is based on type of reaction and patient assessment.

Infant and Child Considerations  A small child may use a mask instead of a mouthpiece. Mask must fit
securely over both nose and the mouth to ensure good seal and prevent
medication escaping.
 Children must be able to seal their lips around the mouthpiece to use a

nebulizer without a mask.