Skills Checklist Manual Alexandra L. Quittner, Ph.D. Kristen K. Marciel, Ph.D. Ivette Cruz, M.S. University of Miami Quittner, Marciel, & Cruz, 2009 i revised 2/5/09
Table of Contents Instructions 1 Airway Clearance ABI Vest Airway Clearance Checklist 2 Positive Airway Pressure (PEP) Mask Checklist 3 Flutter Airway Clearance Checklist 4 Chest Physical Therapy Checklist 6 Acapella Airway Clearance Checklist 7 Metered Dose Inhaler Metered Dose Inhaler Checklist 9 Metered Dose Inhaler with Aerochamber Checklist 11 Nebulizer Checklist 13 Diskus Dry Powder Inhaler Checklist 15 Pulmicort Turbuhaler Dry Powder Inhaler Checklist 16 Enzyme Checklist 17 Quittner, Marciel, & Cruz, 2009 ii revised 2/11/09
Instructions for Administration Introduction: This manual contains checklists that assess whether a patient with CF is using the correct skills while performing his/her prescribed treatments. Please select only the checklists that are currently relevant for that person and ask him/her to show you how they typically do their treatment (e.g., vest, Flutter ). These skills can be observed and assessed by any member of the CF Team with expertise in this area. For example, respiratory therapists or physical therapists are often best trained on airway clearance techniques. Directions: These skills should be observed by a member of the CF Team. Please ask the patient to show you how they perform each treatment (e.g., airway clearance, use of a metered-dose inhaler). As you observe them performing these skills, give them one (1) point for each skill they perform correctly and a zero (0) for each skill that they miss or do not perform correctly. Please do not provide guidance or suggestions during the assessment process. Scoring: Please give one (1) point for each skill on the checklist that is performed correctly and a zero (0) if that skill is missed or performed incorrectly. Please add up the points each person obtained and include at the bottom of each checklist. When scoring the points for each skill on the checklist, please consider individual clinic differences. For example, if your clinic teaches a slightly different technique, please give credit as appropriate according to your clinic s instructions. Similarly, some families may have newer or older device models. Again, give credit as you see appropriate taking their device model into consideration. After determining the gaps in skills, please use this opportunity to re-teach skills and techniques as needed. Quittner, Marciel, & Cruz, 2009 1 revised 2/14/09
ABI Vest Airway Clearance Checklist 1. Waits at least 30-60 minutes after meal before using vest (this can be asked: When do you do your vest? How soon after eating? ). 2. Sits upright or stands for therapy. 3. Puts on vest, ensuring that the shoulder straps are adjusted so that the bottom of the vest is even with the top of the hipbone. 4. Connects hoses between generator & the vest and twists while attaching hoses. 5. Turns on the generator by depressing the blue power button and waits a few seconds while the generator pressurizes and the wait light turns off. 6. Sets pressure and frequency to prescribed levels and changes at prescribed intervals and timer to 5 minutes. 7. Takes a deep breath every 2-3 minutes. 8. After therapy is completed huffs several times to mobilize mucus, then coughs to clear all loosened secretions. Continues to huff and cough until all loosened secretions are cleared. 9. Turns the generator off, disconnects the hoses from the vest, and removes the vest. # correct: /9 Quittner, Marciel, & Cruz, 2009 2 revised 2/14/09
Positive Airway Pressure (PEP) Mask Checklist 1. Sits upright. 2. Holds mask tightly against face. 3. Breathes in normally (normal size breath, normal speed breath). 4. Breathes out using stomach (abdominal) muscles to help force air through the resistor. 5. Repeats steps 3 and 4 for 15 repetitions. 6. Removes mask from face and does 2 or 3 forced expirations or huffs. 7. Coughs to remove any secretions. 8. Rests for 1 or 2 minutes. 9. Repeats cycles of 15 breaths, 2-3 huffs, and cough for approximately 6 cycles. # correct: /9 Quittner, Marciel, & Cruz, 2009 3 revised 2/14/09
Flutter Airway Clearance Checklist Mucus loosening and Mobilization: 1. Sits up straight with head tilted slightly upward. May rest elbows on a table if this is most comfortable. 2. Makes sure Flutter is positioned to give the greatest fluttering sensation (generally so that the mouthpiece is parallel with the floor). 3. Inhales through nose beyond a normal breath, but without filling lungs completely, and holds breath for 2 to 3 seconds. 4. Places Flutter in mouth and exhales to a normal level at a constant speed (not too fast or too hard) while keeping cheeks firm and flat (not puffed out). 5. Repeats steps 1 through 5 for 5 to 10 breaths while suppressing cough. Mucus Elimination: 6. Inhales through nose slowly and as fully and deeply as comfortably possible. Holds breath for 2 to 3 seconds. 7. Exhales forcefully and completely through Flutter while keeping cheeks firm and flat (not puffed out) to trigger cough. 8. Coughs out or huffs out mucus. 9. Repeat steps 6 through 8 once if needed to expel mucus. 10. Repeats steps 1 through 9 for 5 to 15 minutes as prescribed or until no more mucus is coughed up. # correct: /10 Quittner, Marciel, & Cruz, 2009 4 revised 2/14/09
Flutter Airway Clearance Checklist (You can ask these questions) Cleaning the Flutter after each use: 1. Takes Flutter apart and rinses 4 parts with sterile water. 1 2. Wipes dry with a clean towel. 3. Reassembles and stores in a clean, dry place. Cleaning the Flutter every 2 days: 4. Takes Flutter apart and washes 4 parts with soap and sterile water. 1 5. Rinses with sterile water. 1 6. Dries thoroughly with a clean cloth or paper towel. 7. Reassembles and stores in a clean, dry place. Disinfecting the Flutter as prescribed: 8. Soaks the already-cleaned Flutter parts in 1 part alcohol and 3 parts sterile water 1 for 15 minutes. 9. Rinses with sterile water. 1 10. Dries thoroughly with a clean cloth or paper towel. 11. Reassembles and stores in a clean, dry place. # correct: /11 1 DO NOT USE WATER FROM THE FAUCET, BOTTLED, OR DISTILLED WATER. You can make water sterile by boiling it for 5 minutes. Use this water once, and then throw it out. Quittner, Marciel, & Cruz, 2009 5 revised 2/14/09
Chest Physical Therapy Checklist 1. Waits at least 1 ½ to 2 hours after meals before beginning CPT (you can ask this question). 2. Uses bronchodilator prior to CPT if prescribed (you can ask this question). 3. No bare skin (you can ask this question). 4. Pt. is positioned comfortably with pillows, foam wedges, sofa cushions, beanbags, or on tilt table. Head is supported. 5. Caregiver holds hand in correct cupped position for clapping. A. Caregiver percusses for 4-6 minutes each (in any order): 6. Top of shoulders between scapula and collarbone on left and right side. Pt. sits, leaning back slightly against pillow. 7. Upper chest on left and right side between the collarbones and nipples, avoiding sternum (bone in middle of chest), and breasts. Pt. lays flat on back or sits up, leaning back slightly against pillow. 8. Upper back over scapula on left and right side, avoiding spine. Pt. sits, leaning forward over pillow. 9. Lower back on left and right side, below the scapula and above the edge of the rib cage. Pt on stomach, trunk, and head slanting down. 10. Left side of trunk from just below armpit to bottom of rib cage. Pt on right side, head, & trunk slanting down. 11. Right side of trunk from just below armpit to bottom of rib cage. Pt. on right side, head, & trunk slanting down. 12. Lower chest on left and right side, below the nipples and above the edge of the rib cage. Pt on back, trunk, and head slanted down. 13. Pt. huffs and coughs after CPT in each position in order to mobilize and clear mucus. # correct: /13 Quittner, Marciel, & Cruz, 2009 6 revised 2/14/09
Acapella Airway Clearance Checklist How to Use the Acapella 1. Knows how to set the dial to increase or decrease resistance. 2. Sits up with good posture to use the Acapella. 3. Takes a deep breath and holds it for about 3 seconds. 4. Place the Acapella mouthpiece in mouth and seals lips tightly around the mouthpiece. 5. Exhales as much as possible (but not too forcefully) through the mouthpiece, keeping cheeks as firm as possible when exhaling. 6. Repeats this maneuver for 10 breaths and tries to resist coughing during the breaths. 7. After these 10 blows, performs 3 huffs, then a big cough to bring the sputum up and out. Tries not to swallow the mucus. 8. Uses a huffing cough with 3 rapid exhalations with the airways open, making a ha, ha, ha sound. 9. Repeats steps 1 through 10 for 15 minutes 2 to 4 times a day (or as prescribed by your health care provider). (Ask about this) # correct: /9 Quittner, Marciel, & Cruz, 2009 7 revised 2/14/09
Acapella Airway Clearance Checklist (You may ask these questions) How to Clean and Care for the Acapella (green or blue) 1. Washes his/her hands. 2. Cleans the Acapella every day with sterile water 1 and dish soap. 3. Takes the mouthpiece off the Acapella body and washes mouthpiece and body separately. 4. Cleans weekly with alcohol or hydrogen peroxide. # correct: /4 1 DO NOT USE WATER FROM THE FAUCET, BOTTLED, OR DISTILLED WATER. You can make water sterile by boiling it for 5 minutes. Use this water once, and then throw it out. Quittner, Marciel, & Cruz, 2009 8 revised 2/14/09
Metered Dose Inhaler Checklist 1. Inserts metal canister into plastic holder. 2. Removes cap from the inhaler. 3. Shakes the inhaler 3 to 5 times. 4. Exhales. 5. Puts mouthpiece of inhaler into mouth, keeping tongue under inhaler, and closes lips tightly around mouthpiece. 6. Presses down on the MDI at the very beginning of a long, slow, deep breath. 7. Removes MDI from mouth and holds breath to a count of 10. 8. Exhales gently. 9. Repeats steps 3 through 8 as prescribed. If using a bronchodilator, waits 1 to 2 minutes between puffs (you can ask this). # correct: /9 Quittner, Marciel, & Cruz, 2009 9 revised 2/14/09
Metered Dose Inhaler Checklist (You may ask these questions) Daily Cleaning of the plastic holder: 1. Removes canister from holder. 2. Runs warm sterile water 1 through plastic holder and cap. 3. Shakes off excess water. 4. Lets air dry. # correct: /4 1 DO NOT USE WATER FROM THE FAUCET, BOTTLED, OR DISTILLED WATER. You can make water sterile by boiling it for 5 minutes. Use this water once, and then throw it out. Quittner, Marciel, & Cruz, 2009 10 revised 2/14/09
Metered Dose Inhaler with Aerochamber Checklist 1. Inserts the metal canister into plastic holder. 2. Removes the cap from the plastic holder and inserts the inhaler into the back of the chamber. 3. Shakes chamber and MDI 3 to 5 times. 4. Exhales. 5. Places mouthpiece into mouth. 6. Presses down on the MDI and then takes a slow, deep inhalation. 7. Holds breath for a count of 10. 8. Takes mouthpiece out of mouth and exhales gently. 9. Repeats steps 3 through 8 as prescribed. If using a bronchodilator, waits 1 to 2 minutes between puffs (you can ask this). # correct: /9 Quittner, Marciel, & Cruz, 2009 11 revised 2/14/09
Metered Dose Inhaler with Aerochamber Checklist (You may ask these questions) Weekly cleaning of Aerochamber: 1. Soaks in warm sterile soapy water 1 for 15 minutes and agitates gently. 2. Does not rinse (rinsing with plain water causes static electricity, which causes medicine to stick inside the chamber instead of going into the lungs). 3. Shakes out excess water (does not towel dry as this causes static electricity, which causes medicine to stick to the inside of the chamber). 4. Lets air dry in a vertical position. # correct: /4 1 DO NOT USE WATER FROM THE FAUCET, BOTTLED, OR DISTILLED WATER. You can make water sterile by boiling it for 5 minutes. Use this water once, and then throw it out. Quittner, Marciel, & Cruz, 2009 12 revised 2/14/09
Nebulizer Checklist (Ask parents how they mix meds) 1. Twists off top of medicine cup, adds medicine, and replaces top. 2. Attaches one end of tubing to nebulizer cup and the other end to the compressor. 3. Sits upright, holds nebulizer upright and places mouthpiece in mouth (or mask over mouth and nose). 4. Turns on the compressor power switch. 5. Breathes normally through the mouth (uses nose clips if necessary) 6. Takes a deep breath every minute or so to bring medicine farther into lungs. 7. Turns off the compressor when the mist stops. # correct: /7 Quittner, Marciel, & Cruz, 2009 13 revised 2/14/09
Nebulizer Checklist (You may ask these questions) Cleaning nebulizer after each use: 1. Removes tubing from nebulizer. 2. Takes apart the nebulizer: removes cap, mouthpiece or mask, and the piece down inside the cup. 3. Rinses each part with warm sterile water 1, shakes off excess water, and sets on a towel to air dry (does not rinse tubing). Disinfecting nebulizer each day it is used: (Ask parents what they use to clean the nebulizer and where they soak the nebulizer.) 4. Soaks each piece (not tubing) in Control III for 5 minutes. 5. Rinses with clean sterile water 1, shakes off excess water, and sets on towel to air dry. Compressor care: 6. Covers with a clean cloth when not in use. 7. Keeps compressor clean by wiping with a clean damp cloth as needed. 8.Replaces or cleans compressor filter as directed by equipment supplier. # correct: /8 1 DO NOT USE WATER FROM THE FAUCET, BOTTLED, OR DISTILLED WATER. You can make water sterile by boiling it for 5 minutes. Use this water once, and then throw it out. If you disinfect by boiling, you do not need to rinse the nebulizer. Quittner, Marciel, & Cruz, 2009 14 revised 2/14/09
Diskus Dry Powder Inhaler Checklist 1. Holds diskus in one hand with thumb grip facing up. 2. Placing thumb of other hand in thumb grip, pushes thumb away so that cover slides away and mouthpiece snaps into position. 3. Holds diskus in a level, horizontal position with mouthpiece facing toward mouth. 4. Slides lever away as far as it will go until it clicks. Does this only once. 5. Turns head to avoid breathing into mouthpiece, then breathes out as far as is comfortable. 6. Puts mouthpiece to lips and breathes in through mouth quickly and deeply. 7. Removes diskus from mouth and holds breath for 10 seconds. 8. Breathes out slowly. 9. Closes diskus by holding diskus in one hand, placing thumb of other hand in thumb grip and sliding it back as far as it will go. 10. Rinses mouth after using. 11. Stores diskus in a dry place. Never washes diskus keeps it dry at all times. # correct: /11 Quittner, Marciel, & Cruz, 2009 15 revised 2/14/09
Pulmicort Turbuhaler Dry Powder Inhaler Checklist A. If the Turbuhaler is new and has never been used, primes Turbuhaler : 1. Turns cover and lifts off. 2. Holds Turbuhaler upright (with mouthpiece up), then twists the brown grip fully to the right and back again to the left, until click is heard. 3. Repeats above step. B. Releases dose: 4. Twists the cover and lifts off. 5. Holds Turbuhaler in an upright position (mouthpiece up) and twists the brown grip fully to the right as far as it will go. 6. Twists brown grip back again fully to the left (hears click). 7. Turns head away from inhaler and breathes out. Does not breathe or exhale into inhaler. C. Inhales the dose: 8. Holds Turbuhaler either in upright (mouthpiece up) or horizontal position. 9. Places mouthpiece between lips and inhales forcefully and deeply. (If more than one dose is required, repeats steps 2 through 4.) 10. When finished, places cover back on inhaler and twists shut. 11. Rinses mouth with water. Does not swallow. 12. Stores Turbuhaler in a dry place at controlled room temperature (68 to 77 degrees). # correct: /12 Quittner, Marciel, & Cruz, 2009 16 revised 2/14/09
Administration of Enzymes Checklist 1. Takes enzymes at correct time in relation to meals (at beginning of meal, not before or after). 2. Dispenses correct dosage from bottle, varying with size of meal (ask which foods require more enzymes). 3. Swallows enzyme tablets whole or broken open in soft food (e.g., applesauce or pudding). Does not chew. 4. If enzymes are broken open in food, swallows enzymes immediately. 5. Stores in dark, cool place (you can ask this question) # correct: /5 Quittner, Marciel, & Cruz, 2009 17 revised 2/14/09