Effective Date: August 31, 2006 SUBJECT: CARE AND USE OF NEBULIZER AND INTERMITTENT POSITIVE PRESSURE BREATHING DEVICE

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1 COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 421 Effective Date: August 31, 2006 SUBJECT: CARE AND USE OF NEBULIZER AND INTERMITTENT POSITIVE PRESSURE BREATHING DEVICE 1. PURPOSE: This policy will provide guidelines for the appropriate use and care of nebulizer and/or Intermittent Positive Pressure Breathing (IPPB) equipment for aerosol therapy at this facility. 2. POLICY: 1. The nebulizer and/or IPPB shall only be used for aerosol therapy upon the valid order of a physician, which must include all components of an order. 2. The nebulizer and/or IPPB are not intended for use in emergency situations. However, if the individual is currently on nebulizer treatment and has an order for PRN use, it may be used for a respiratory crisis. 3. The nebulizer and/or IPPB equipment in use a this facility includes a compressor designed for frequent, short-term usage. Do not leave the compressor on unless providing aerosol therapy. 4. The nebulizer and/or IPPB equipment will be provided by Central Supply via appropriate request. The equipment shall be returned to Central Supply, after appropriate cleaning, when no longer needed. 5. Each individual utilizing the nebulizer and/or IPPB shall have his/her own mouthpiece. These mouthpieces shall not be shared. 6. The Unit Supervisor/designee shall ensure that appropriate cleaning/maintenance is performed by unit nursing staff, per manufacturer s guidelines, while the equipment is in use on their unit. 3. GENERAL INFORMATION: The nebulizer system provides a safe, effective and simple means of delivering medication in aerosol form, converting liquid topical medication into a mist that is inhaled into the bronchial tree for therapeutic reasons. Some of the droplets of the mist are microscopic, allowing deeper -1-

2 penetration throughout the lungs and maximum distribution of the medication. There are two basic therapeutic reasons for the use of aerosolized medication: 1.) Some medications are capable of reversing bronchospasms that occur in a variety of respiratory disorders. These medications act almost immediately on contact with the tissue of the respiratory tract to relax smooth muscles that cause these spasms, thus re-opening airways and restoring normal ease of breathing. 2.) Other medications are commonly used to thin and loosen secretions within the respiratory system, thus unblocking the path that air normally takes in entering and filling the lungs. When thick sputum is made thinner and loosened, it can be coughed up and expelled. Some of the different types of medications that are prescribed for aerosolized use are: A. Bronchodilators relax smooth muscles of the respiratory tract, and are considered topical because they work on contact with the lining of the bronchial tree. Smooth muscles tighten during bronchospastic attacks and make breathing difficult due to the resultant narrowing of the airways. B. Mucolytics chemically break down the viscid secretions that are difficult to cough up. Once thinned, these secretions become much easier to mobilize, thus unblocking airways of the respiratory tract. C. Wetting Agents these are used to hydrate (humidify) the secretions, making them thinner and loose. Are also used as mixers for other medications that need to be diluted, such as bronchodialators. D. Antibiotics a variety of antibiotics may be used to fight infection in the respiratory tract and are occasionally used in aerosol form. E. Steroids these are used to shrink swelling and lessen irritation of tissue and are occasionally used in aerosol form. 4. GENERAL PRECAUTIONS: 1. Always unplug equipment immediately after using. 2. Do not use near water. Do not place in or store equipment where is could fall or be pulled into a tub or sink. Do not place or drop into water or other liquid. 3. Do not leave unattended when plugged in. 4. Never operate equipment if it has been dropped or damaged, or dropped into water. -2-

3 5. Plug equipment into a properly grounded outlet only. Keep the cord away from heated surfaces. 6. Never block the air openings of equipment or place it on a soft surface (e.g. bed) where the air openings may be blocked. Keep the air openings free of lint, hair, or other debris. Never drop or insert an object into any openings. 7. Do not operate where other aerosol (spray) products are being used or where oxygen is being administered. 5. PROTOCOL: NEBULIZER EQUIPMENT NURSING ACTION A. Assemble equipment and appropriate medication. B. Take equipment and medication to the area where it is to be used (Individual bedroom, treatment room). C. Provide appropriate teaching to the individual regarding procedure. D. Place the compressor on a flat, firm surface and near an appropriate, grounded outlet. E. Attach the clear connecting tubing to the compressor (top front portion). F. Unscrew the nebulizer cup and place it on a clean, flat surface. G. Check physician s order for type and amount of medication prescribed, then pour medication into nebulizer cup. H. Screw the nebulizer cup back onto the nebulizer assembly. I. Have the individual hold the nebulizer assembly and plug the compressor into the grounded wall outlet. KEY POINTS A. Compare physician s order to medication in cassette. B. Ensure there is an appropriate place to put the equipment (e.g. nonsoft surface) and a grounded outlet to plug it into. C. Make sure that the individual understands and can/will cooperate. D. Ensure that air vents are not blocked. E. Ensure tubing is clean and intact. F. Staff may complete this nursing action in the medication room. G. Follow the six rights of medication administration. H. Make sure that liquid does not spill out. I. Make sure individual holds cups and assembly level, so that liquid does not spill. -3-

4 J. Switch the compressor on, switch is located on the back portion of the unit. K. Instruct the individual to place the mouthpiece between his/her teeth and breath through it until all of the medication is used up. If using a mask, instruct individual to inhale and exhale through the mask, as prescribed by the physician. L. Keep the nebulizer cup upright at all times to ensure adequate nebulization of the medication. J. When on, the air going through the nebulizer will create a hissing noise and you will see droplets forming inside the nebulizer cup. K. Nebulizer come with mouthpiece as standard equipment. May also be used with a mask, if ordered by the physician. Remove T-connector from the assembly and attach the assembly to the mask. L. Adequate nebulization of the medication is necessary to ensure that all medication is given as ordered. Care and cleaning of the nebulizer equipment: NURSING ACTION A. The manufacturer recommends daily disinfection of the nebulizer assembly if used on a daily basis. CSH Infection Control Policy requires the same. B. Use an appropriate, Infection Control Committee approved disinfection solution. C. To clean calcium deposits, use a solution white vinegar (1/2 cup) to 1 quart of warm water. D. Soak the entire assembly in the solution for at east 15 minutes. E. The nebulizer assembly is considered a single use, disposable item. It is not to be shared between individuals, and should be appropriately disposed of after the individual has completed their prescribed treatment. Dispose in trcsh unless grossly contaminated KEY POINTS A. Each individual shall use his/her own nebulizer assembly, per Infection Control Policy and Practices. B. Refer to Infection Control Policy for list of approved cleaning and disinfecting agents. C. Manufacturer recommends replacement of nebulizer assembly after 2 to 3 weeks of continuous use. D. Rinse after soak and allow to air dry. E. Consult with Central Supply for replacement nebulizer assembly if the individual remains on treatment for a prolonged period of time (e.g. longer than 2-3 weeks). -4-

5 with mucus or other bodily fluids, then dispose as Biohazardous Waste. F. The compressor unit is not disposable and should be returned to Central Supply for re-issue when no longer needed on the unit. The Unit Supervisor/designee shall ensure that it is properly cleaned prior to its return. F. DO NOT soak the compressor. SO NOT use water or any other liquid to clean the compressor. Wipe clean with a cloth. Procedure: intermittent positive pressure breathing (IPPB): NURSING ACTION A. Check the physician s order. Follow the six rights of medication administration. B. Assemble equipment. Take equipment and medication to the area where it is to be used (individual bedroom, treatment room). C. If applicable, pre-set PSI setting before initiation of treatment. To do this, pull regular knob (located in the front of compressor ) to unlock the regulator, occlude mouthpiece to simulate a tight lip seal and adjust the settings accordingly. If unable to, adjust dials to lowest settings before initiation of treatment. D. Provide appropriate teaching to the individual regarding the procedure. E. Place the compressor on a flat, firm surface and near an appropriate, grounded outlet. F. Attach the clear connection tubing to the compressor (front portion). KEY POINTS A. Ensure that there is a current complete order including but not limited to PIP settings (L/min), inspiratory flow rate (cm-h2o) and medication with dosage. B. Ensure there is appropriate place to put the equipment (e.g. non-soft surface) and a grounded outlet to plug it into. C. This action assures correct settings, minimizes risks of over hyperinflation of lungs and provides more time for individual focused teachings regarding procedure. D. Make sure that the individual understands and can/will cooperate with the procedure. E. Ensure that air vents are not blocked. F. Ensure tubing is clean and intact. -5-

6 G. Unscrew the nebulizer cup and place it on a clean, flat surface. H. Check physician s order for type and amount of medication prescribed, then pour medication into nebulizer reservoir. I. Screw the nebulizer cup back onto the nebulizer assembly. J. Have the individual hold the water trap upright and plug the compressor into the grounded wall outlet. K. Switch the compressor on, switch is located on the back portion of the unit. L. Instruct the individual to place the mouthpiece between his/her teeth and breath through it. Set PIP settings then adjust the rate dial to individual s comfort. M. Keep the nebulizer cup upright at all times to ensure adequate nebulization of the medication. Give Individual intermittent rest periods lasting one minute to freely cough and deep breathe. G. Staff may complete this nursing action in the medication room. H. Follow the six rights of medication administration. I. Make sure that liquid does not spill out. J. The water trap component serves as the holding device for the assembly. Holding it upright ensure that liquid does not spill. K. When the compressor is on, the mouthpiece emits aerosolized medication. L. IPPB devices come with mouthpiece as standard equipment. Ensure PIP settings are adjusted according to physician s order. Ensure the rate dial is adjusted to individual s comfort by asking the individual. M. Adequate nebulization of the medication is necessary to ensure that all medication is given as ordered. Intermittent rest periods provide opportunities for sufficient cough and deep breathing exercises. Care for cleaning of the ippb equipment: -Refer to manufacturers instructions/guidelines. 6. EVALUATION: Documentation should include the following: 1. Date, time and problem number 2. Vital signs, including pain and sp02, pre and post treatment 3. Medication and dosage, equipment used (IPPB or nebulizer) -6-

7 4. Tolerance to treatment 5. Other relative information 7. MAINTENANCE AND CLEANING RECORD FOR THE IPPB: Individual s Name: Unit: KEY POINTS: 1. Filters check for dust build-up. Weekly and/or as needed to clean, remove from their recessed areas and wash in warm soapy water and rinse. Absorb excess water from filter with dry towel and replace to their original locations. Change q 30 months. 2. Nebulizer assembly: End of the day use. Disconnect the modulator and water trap component from the nebulizer assembly. Unscrew nebulizer top, rinse with warm soapy solution, final rinse with warm water and allow to air dry for next day s use. Ivory soap is recommended due to its water-based properties. Wipe the external part of the machine as needed with a cloth. 3. Rinse the nebulizer component with warm water after each treatment to wash off medication left in the nebulizer reservoir (refer to key point #2 for disconnecting the component). The manufacturer recommends an end of day use rinse with warm water and mild soap solution (refer to key point #2). 4. Compressor: wipe clean with a cloth as needed. 5. Oxygen tubing: change as needed and/or every 30 days. THIS FORM IS TO BE INITIALED AND DATED WHEN ITEMS ARE COMPLETED Date: Air Filter C=Cleaned R=Replaced 02 Tubing replaced Filter UNIT MAINTENANCE RECORD: 02 tubing replaced Q 30 d: Last Next Additional copies of this form may be obtained from Central Supply as needed. -7-

8 Forward this form to Medical Services when complete to when individual returned to court. Keep copies of this record at unit level. -8-