Teaching a Patient to Use a Peak Flow Meter

Skill 14-2

Teaching a Patient to Use a Peak Flow Meter

Peak expiratory flow rate (PEFR) refers to the point of highest flow during forced expiration, measured in liters per minute (LPM). PEFR reflects changes in the size of pulmonary airways and is measured using a peak flow meter (Figure 1). A peak flow meter can be an important part of an asthma management plan as well as management of chronic bronchitis and emphysema (American Lung Association, 2020a). Peak flow measurements can provide information about day-to-day changes in the patient's breathing to guide care decisions, including treatment and medication, as well as measure the severity of the disease, degree of disease management, and disease exacerbations (MFMER, 2020). In order to obtain consistent readings, the patient should use the same peak flow meter on a routine basis (Hess et al., 2021). There are many commercially available peak flow meters; refer to the manufacturer's guidelines for the specific device in use.

The individual patient's personal best peak flow provides the benchmark value for their asthma management plan (Hess et al., 2021; MFMER, 2020). The personal best peak flow is identified by measuring the daily peak flow rate over a 2- to 3-week period; the highest peak flow rate over this period is the patient's personal best (AAFA, 2017; MFMER, 2020).

Delegation Considerations

Patient teaching related to the use of a peak flow meter is not delegated to assistive personnel (AP) or to licensed practical/vocational nurses (LPN/LVNs). Depending on the state's nurse practice act and the organization's policies and procedures, the LPN/LVN may reinforce and encourage the use of the incentive spirometer by the patient. 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

Peak flow meter
Stethoscope
PPE, as indicated

Assessment

Auscultate the lungs (see Skill 3-5). Assess vital signs and oxygen saturation. Ask the patient about symptoms, including shortness of breath, wheezing, coughing, chest tightness, and ability to complete activities of daily living. Ask the patient about their use of prescribed medications, including inhaled and oral. Assess the patient's understanding of the use of a peak flow meter.

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:

Impaired gas exchange
Activity intolerance
Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve when teaching a patient to use a peak flow meter is that the patient accurately demonstrates the procedure for using the meter. Other outcomes that may be appropriate include that the patient verbalizes an understanding of and engages in the plan of care.

Implementation

Action	Rationale
1. Review the patient's health record for any health problems that would affect their oxygenation status. Gather equipment.	Identifying influencing factors aids in interpretation of results. Assembling equipment provides for an organized approach to the task.
2. 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.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
6. Assist the patient to a standing position if they are able, otherwise, to an upright position, if possible.	An upright position facilitates lung expansion.
7. Move the marker on the meter to the bottom of the numbered scale. Connect the mouthpiece to the meter if it is not already connected.	This starts the measurement at “0” and allows for an accurate reading. The mouthpiece is required to use the meter.
8. Instruct the patient to take a deep breath, filling their lungs completely, and then hold their breath. Have the patient place the meter in their mouth, between their teeth with their tongue under the mouthpiece, and then close their lips tightly around the mouthpiece (Figure 2).	The patient should fully fill their lungs so that the maximum volume may be exhaled. The tongue under the mouthpiece prevents the tongue from blocking the hole in the mouthpiece (AAFA, 2017). A tight seal allows for maximum use of the device.
9. Instruct the patient to blow out as hard and as fast as they can in a single blow (Figure 3).	The meter measures the force of the air coming out of the lungs, indicating how open the airways are in the lungs (Cleveland Clinic, 2020).
10. Note the final position of the marker on the gauge on the meter and write it down.	The marker on the meter moves during exhalation, to gauge the point of highest flow.
11. Instruct the patient to remove their lips from mouthpiece and breathe normally. If the patient coughs when using the meter or makes a mistake in the steps, instruct them to not record the number and to repeat the reading (AAFA, 2017).	Coughing or other mistakes in the process may result in inaccurate readings.
12. Instruct the patient to blow into the meter two more times. The highest number of the three should be recorded in the patient's asthma diary.	Use of the highest of three measurements takes patient effort into consideration and provides more accurate representation of the patient's status.
13. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
14. Clean the peak flow meter weekly with warm water and a mild detergent or according to the manufacturer's instructions (MFMER, 2020).	Cleaning the equipment deters the spread of microorganisms and contaminants (American Lung Association, 2020a).

Evaluation

The expected outcomes have been met when the patient has correctly demonstrated the procedure for use of the peak flow meter has verbalized an understanding of the importance of and rationale for use of the meter.

Documentation

Guidelines

Document that the peak flow meter was used by the patient, the number of repetitions, and the highest measurement. Document patient teaching and patient response, if appropriate. If the patient reports signs and/or symptoms of cough, document whether the cough is productive or nonproductive. If productive cough is present, include the characteristics of the sputum, including consistency, amount, and color.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient attempts to inhale on the meter: Remind the patient that they are exhaling into the meter. They should blow a fast, hard blast to empty their lungs (American Lung Association, 2020a).
Each of three measurements at one use are very different: Assess the patient's effort and technique in using the device. Remind the patient that it is important to inhale completely and blow out has hard and fast as they are able in a single burst of air. Check that the patient is not spitting or thrusting their tongue when blowing out.

Special Considerations

General Considerations

It is important for the patient to know their peak flow reading, but it is even more important for them to know what to do based on that reading (American Lung Association, 2020a). The patient should refer to the Asthma Action Plan developed with their health care team (American Lung Association, 2020a).
A decrease in peak flow of 20% to 30% of a person's personal best may indicate the start of an asthma episode (AAFA, 2017).
The American Lung Association (2020a) provides a video showing patients how to use a peak flow meter at https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/measuring-your-peak-flow-rate.
In order to obtain consistent readings, the patient should use the same peak flow meter on a routine basis (AAFA, 2017; Hess et al., 2021).
Patients should collaborate with their health care team regarding the frequency of checking their peak flow (MFMER, 2020).
Peak flow readings can be artificially high if the patient thrusts their tongue or spits during the measurement. Peak flow readings can be artificially low due to not enough effort or poor technique (AAFA, 2017).
A common mistake is to attribute low measurements to poor effort or lack of cooperation when airway obstruction is actually present (Hess et al., 2021).

Infant and Child Considerations

Children ages 5 years and older are usually able to use a peak flow meter to help manage their asthma (American Lung Association, 2020a).
Meters come in two ranges to measure the air pushed out of the lungs; small children need to have a low-range peak flow meter (American Lung Association, 2020a).

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Skill 14-2