Administering Medication Via a Small-Volume Nebulizer

Skill 5-24

Administering Medication via a Small-Volume Nebulizer

Drugs for inhalation may be administered via a small-volume nebulizer . Nebulizers utilize the force of high-flow oxygen or compressed air through a fluid medication to disperse fine particles of liquid medication into the deeper passages of the respiratory tract, where absorption occurs. The nebulizer medication treatment continues until all the medication in the nebulizer cup has been inhaled.

Delegation Considerations

The administration of medication via a nebulizer is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, administration of medication using a nebulizer may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Stethoscope
Prescribed medication
Nebulizer tubing and chamber
Air compressor or oxygen hookup
Sterile saline (if medication is not premeasured)
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)
PPE, as indicated

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Assess respiratory rate, rhythm, effort, and depth to establish a baseline. Assess lung sounds before and after use to establish a baseline and determine the effectiveness of the medication. Assess the peak flow before and after administration to establish a baseline and determine the effectiveness of the medication. If appropriate and/or prescribed, assess oxygen saturation level before and after medication administration. The oxygenation level usually increases after the medication is administered. Assess the patient's ability to manage a nebulizer. Assess the patient's knowledge and understanding of the medication's purpose and action. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered breathing pattern
Impaired gas exchange
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve are that the medication is administered and breathed in by the patient, and the patient experiences the intended effect of the medication. Other outcomes that may be appropriate include the following: the patient verbalizes an understanding of and engages with the medication regimen, and the patient demonstrates correct use of the nebulizer.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
10. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
11. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
12. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
13. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
14. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
15. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
16. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain what you are going to do, and the reason for doing it, to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, promotes patient engagement, and reduces anxiety.
17. Scan the patient's bar code on the identification band, if required (The Joint Commission, 2021).	Scanning provides an additional check to ensure that the medication is given to the right patient.
18. Based on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps to prevent errors.
19. Remove the nebulizer cup from the device and open it. Place a premeasured unit-dose medication in the bottom section of the cup or use a dropper to place a concentrated dose of medication in the cup (Figure 1). Add prescribed diluent (usually saline), if required.	To get enough volume to make a fine mist, normal saline may need to be added to the concentrated medication.
20. 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.	Air or oxygen must be forced through the nebulizer to form a fine mist.
21. Turn on the air compressor or oxygen (flow of 6 to 8 L/min [Hess et al., 2021]). Check that a fine medication mist is produced by opening the valve. Have the patient place the mouthpiece into the mouth and grasp securely with their 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.
22. Instruct the patient to breathe normally through the mouth with occasional deep breaths (Figure 2). A nose clip may be necessary if the patient is also breathing through the nose.	While the patient inhales, the medication comes in contact with the respiratory tissue and is absorbed.
23. 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.
24. When the medication in the nebulizer cup has been completely aerosolized, the cup will be empty and no more aerosol will be produced. Have the patient remove the nebulizer from their mouth and gargle and rinse with tap water, as indicated. Clean and store the nebulizer and equipment according to the manufacturer's directions and facility policy.	Rinsing is necessary when using inhaled steroids because oral fungal infections can occur. Rinsing removes medication residue from the mouth. The buildup of medication in the device can affect how the medication is delivered as well as attract bacteria.
25. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
26. Document the administration of the medication immediately after administration. See Documentation section below.	Timely documentation helps to ensure patient safety.
27. Evaluate the patient's response to the medication within an appropriate time frame. Reassess lung sounds, oxygen saturation level, peak flow, and respirations, as indicated.	The patient needs to be evaluated for therapeutic and adverse effects from the medication. Lung sounds and oxygen saturation level may improve after nebulizer use. Respirations may decrease after nebulizer use.

Evaluation

The expected outcomes have been met when the medication was administered and breathed in by the patient, the patient has experienced the intended effect of the medication, the patient has verbalized an understanding of and engaged with the medication regimen, and the patient has demonstrated correct use of the nebulizer.

Documentation

Guidelines

Document the administration of the medication immediately after administration, including date, time, dose, and route of administration on the eMAR/MAR or record using the required format. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. Document respiratory rate, oxygen saturation and peak flow measurements, if applicable, lung assessment, and the patient's response to the treatment, if appropriate. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team. This verifies the reason medication was omitted and ensures that health care personnel providing care for the patient are aware of the occurrence.

Sample Documentation

9/29/25

2300 Expiratory wheezes noted in all lungs fields before albuterol nebulizer, O₂ saturation 92%, respiratory rate 24 breaths per minute, patient reports “feeling like I can't get my breath.” Patient reassessed 20 minutes after albuterol nebulizer treatment; lung sounds are clear to auscultation and equal in all lung fields, O₂ saturation 97%, respiratory rate 18 breaths per minute unlabored. Patient verbalized relief of shortness of breath and an understanding of medication purpose and action.

—C. Bausler, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient is unable to hold nebulizer in mouth and/or is unable to keep lips closed around device: A plain oxygen mask can be attached to the nebulizer device and used to deliver the nebulized medication, eliminating the need to hold the device in the mouth.

Special Considerations

General Considerations

Ongoing assessment is an important part of nursing care to evaluate patient response to administered medications and early detection of adverse drug reactions. If an adverse effect is suspected, withhold further medication doses and notify the patient's health care team. 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. The mask must fit securely over both the nose and the mouth to ensure a good seal and prevent medication escaping.
Children must be able to seal their lips around the mouthpiece to use a nebulizer without a mask.

Community-Based Care Considerations

After each dose, the medicine cup and mouthpiece should be washed with water and air dried, while the medicine cup, mouthpiece, or mask should be washed with a mild detergent daily (Cleveland Clinic, 2019). Weekly disinfection is recommended.

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Skill 5-24