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Dec.19.2019

Medication Administration: Nebulized (Pediatric) – CE

ALERT

If bronchospasm occurs during nebulized medication administration, discontinue the medication and notify the practitioner.

Take steps to eliminate interruptions and distractions during medication preparation.

At the completion of the procedure, ensure all choking hazards (e.g., syringe caps, twist-off caps from saline bullets) are removed from the infant’s, toddler’s, and preschool-age child’s bed.

OVERVIEW

Nebulization is the process of aerosolizing a medication.undefined#ref1">1 Nebulized treatments can be given either intermittently or continuously. Nebulizers are the mainstay of medical aerosol therapy in acute and critical care settings. The primary advantage of nebulized medication administration is that it treats the lung directly; however, the medication can be absorbed into the bloodstream via the alveoli.4 In addition, minimal patient cooperation or coordination is required for the treatment. The disadvantage is that lung deposition of the nebulized medication represents a relatively low fraction of the total dose. The lungs of a crying child receive little nebulized medication. Most of the inhaled medication is deposited in the upper airways or pharynx and swallowed. Development of appropriate approaches that minimize distress is essential for administering nebulized medications to a child.

Small-volume nebulizers provide medications in an aerosolized form that the infant or child can inhale into the tracheobronchial tree (Figure 1)Figure 1. These medications bind to the beta-2 receptors in the smooth muscle. Side effects from systemic absorption include tachycardia, arrhythmia, and hypertension.

Selection of the correct nebulizer device is critical for successful administration in infants and children. Young children may not use a mouthpiece reliably. If the child cannot hold a mouthpiece between the lips, a face mask should be used (Figure 2)Figure 2.

Medications such as bronchodilators, mucolytics, corticosteroids, antimicrobials, and antivirals are often administered by nebulization.

Nebulizer sets must be cleaned appropriately; failure to do so leads to a decrease in performance due to clogging of the output orifice on the machine. Child and family education should include effective nebulizer cleaning techniques.

If the child or family expresses concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

CHILD AND FAMILY EDUCATION

  • Provide individualized, developmentally appropriate education to the family and child based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Provide the family and child with appropriate verbal and written information about the medication, including its purpose and the reason for the inhaled nebulized route.
  • Instruct the child and family regarding the potential adverse effects of the medication.
  • Explain to the child and family the step-by-step procedure for nebulized medication administration.
  • Explain how the family can participate during the procedure.
  • Explain how the child can assist with the procedure by taking deep breaths.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Child and Family Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the child and family.
  3. Verify the correct child using two identifiers.
  4. Review the child’s history for reactions or allergies to medications, foods, or environmental allergens.
  5. Assess the child for specific contraindications to receiving the medication and advise the practitioner accordingly.
  6. Assess the child’s developmental level and ability to interact.
  7. Assess the child’s and family’s understanding of the reasons for and the risks and benefits of the procedure.
  8. Assess baseline vital signs, breath sounds, respiratory effort, pulse oximetry reading, and, when indicated and if ordered, peak flow meter reading.
  9. Determine the appropriate delivery device based on an assessment of the child’s age, developmental level, and ability to follow instructions. If the child cannot hold a mouthpiece between the lips, use a face mask.

Preparation

  1. Obtain the child’s weight in kilograms.
  2. Consider consulting a child life specialist if available.
  3. Obtain the medication and verify the expiration date.
  4. Inspect the medication for particulates, discoloration, or other loss of integrity.
    Do not use any medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe; otherwise, this may lead to harmful reactions.
  5. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, common side effects, and nursing implications, if needed.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct child using two identifiers.
  3. Explain the procedure to the child and family and ensure that they agree to treatment.
  4. Check accuracy and completeness of the medication administration record (MAR) with the practitioner’s original order.
  5. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right child, and right documentation. Use a bar code system or compare the MAR to the child’s armband.
  6. Label all medications, medication containers, and other solutions, including those that are on a sterile field. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.3
  7. Assemble the nebulizer equipment according to the manufacturer’s recommendations.
  8. Assist the child into a comfortable sitting or semi-Fowler position as tolerated to support full inhalation. The child may be held in a family member’s lap for optimal positioning, as indicated.
    Rationale: A sitting or semi-Fowler position promotes optimal lung expansion and maximal distribution of aerosolized particles to lung fields.
  9. Add the prescribed medication and diluent if needed to the medication cup of the nebulizer.
    Rationale: Some medications are unit dosed and prediluted; others may require a diluent such as saline to ensure optimal drug delivery.
    Check the required fill volume for the device used.
  10. Turn on the small-volume nebulizer via the flowmeter. Usually, the flow rate is between 6 and 8 L/min and is listed on the device label.1
    Rationale: The correct flow rate ensures that a sufficient mist forms to indicate nebulization is occurring.
  11. If a mouthpiece is used, instruct the child to hold it with the lips, using gentle pressure to form a seal around the tip. If the infant or child is unable to hold the mouthpiece, use a face mask.
    Rationale: A correct fit with a tight seal around the mouthpiece decreases the loss of medication into the air, ensuring delivery of the prescribed dose.
    Make sure the face mask fits tightly and instruct the child to breathe through an open mouth.
  12. Instruct the child to take a deep breath slowly, reaching an air volume slightly greater than normal. Encourage a brief, end-inspiratory pause (breath holding). Then instruct the child to exhale passively.
    Rationale: This technique increases optimal delivery of the medication to the lungs. Normal breathing pattern can be used with the child’s mouth open to provide a direct route to the airways for the medication.
    Medication deposition to the lungs will vary in young children depending on their respiratory rate and depth of breathing during treatment.
  13. Monitor the child’s heart rate periodically during treatment. Discontinue treatment if his or her heart rate rises significantly and notify the practitioner.
    Rationale: Tachycardia is a side effect of bronchodilators; it can lead to hemodynamic instability in small infants and children with cardiac disease.
    Be aware that side effects usually subside shortly after treatment.
  14. When most of the medication dose has been delivered (indicated by sputtering in the medication cup), tap the sides of the cup to drop the medication to the bottom of the cup. The nebulized medication delivery should take approximately 10 minutes.1
    Rationale: Tapping the sides of the cup releases droplets of medication that may adhere to sides of the medication cup. Some medications have a longer nebulization time due to increased viscosity of the liquid.
  15. When treatment is complete, turn off the flowmeter and assess the child’s response to treatment by checking his or her heart rate, respiratory rate, breath sounds, oxygen saturation values, and, if ordered, peak flow readings.
    1. Compare assessment findings with baseline assessment findings to evaluate treatment effectiveness.
    2. For a young child, it may be necessary to wait several minutes after treatment to obtain an accurate heart rate and respiratory rate because the treatment may have agitated the child.
  16. Disassemble all parts of the nebulizer, shake the nebulizer cup to attempt to remove all the remaining solution, rinse each part in sterile or distilled water, shake off excess water, and allow to air-dry completely. Store the nebulizer cup and tubing assembly in a clean bag until its next use.
  17. Praise the child for positive behavior.
  18. Help the child back to a comfortable position.
  19. Discard supplies and perform hand hygiene.
  20. Document the procedure in the child’s record.

MONITORING AND CARE

  1. Monitor the child’s tolerance of the procedure.
  2. Assess for the intended response to medication.
  3. Monitor the child for adverse and allergic reactions to the medication. Recognize and immediately treat dyspnea, wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
    Rationale: Nebulized medications or 0.9% sodium chloride solution may worsen bronchospasm.
    Reportable conditions: Rash, difficulty breathing, seizures

EXPECTED OUTCOMES

  • Medication administered according to the six rights of medication safety
  • Child tolerates medication and experiences no adverse reactions
  • The child and family can state the purpose and side effects of the medication.
  • The child’s breathing pattern and gas exchange improve.

UNEXPECTED OUTCOMES

  • Medication administration not according to the six rights of medication safety
  • No sign of intended response to medication
  • Adverse reaction to the medication
  • Child or family cannot state the purpose and side effects of the medication
  • If taught to administer the medication, the child and family are unable to do so

DOCUMENTATION

  • Child’s weight in kilograms
  • Medication administered, dose, time of administration, person administering it
  • Child’s response to medication, including any adverse reactions
  • Vital signs, oxygen saturation, pulse oximetry reading, peak flow measurements, and lung assessment
  • Unexpected outcomes and related nursing interventions
  • Child and family education

REFERENCES

  1. DiBlasi, R.M. (2015). Clinical controversies in aerosol therapy for infants and children. Respiratory Care, 60(6), 894-916. doi:10.4187/respcare.04137
  2. Institute for Safe Medication Practices (ISMP). (2017). 2018-2019 Targeted medication safety best practices for hospitals. Retrieved October 25, 2019, from https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdf (Level D)
  3. Joint Commission, The. (2019). National patient safety goals: Hospital accreditation program. Retrieved October 25, 2019, from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf (Level D)
  4. Sidler-Moix, A.L. and others. (2015). Physicochemical aspects and efficiency of albuterol nebulization: Comparison of three aerosol types in an in vitro pediatric model. Respiratory Care, 60(1), 38-46. doi:10.4187/respcare.02490 (Level C)

AACN Levels of Evidence

  • Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
  • Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
  • Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
  • Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
  • Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
  • Level M - Manufacturer's recommendations only
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